Healthcare Provider Details

I. General information

NPI: 1902876931
Provider Name (Legal Business Name): MARK ALAN GELLASCH PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRANCH MEDICAL CLINIC NORFOLK 1721 TAUSSIG BLVD
NORFOLK VA
23511
US

IV. Provider business mailing address

2753 SANDPIPER RD
VIRGINIA BEACH VA
23456-4516
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-6377
  • Fax:
Mailing address:
  • Phone: 757-426-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110000034
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: