MEDICARE: MR. MARK DOUGLAS GANEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	312368	LA
2	363A00000X	Physician Assistant	PA09803	TX

General Provider Information

NPI Number	:	1063785681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK DOUGLAS GANEY PA-C

Provider Business Mailing Address
First Line	:	1705 W KENTUCKY AVE
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-9582
Country	:	US
Telephone Number	:	318-355-1373
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 W MISSISSIPPI AVE
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-4202
Country	:	US
Telephone Number	:	318-513-1212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	09/10/2021

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