Healthcare Provider Details

I. General information

NPI: 1578513115
Provider Name (Legal Business Name): MARK D. SUAREZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 MINERAL RD
GLENVILLE WV
26351-1385
US

IV. Provider business mailing address

809 MINERAL RD
GLENVILLE WV
26351-1385
US

V. Phone/Fax

Practice location:
  • Phone: 304-462-7322
  • Fax: 304-462-4052
Mailing address:
  • Phone: 304-462-7322
  • Fax: 304-462-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number869
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: