MEDICARE: MR. MARK STEVENS FORD 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	363AS0400X	Surgical Physician Assistant	0110001015	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4330530001	OTHER		DMERC

General Provider Information

NPI Number	:	1710964812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK STEVENS FORD PA-C

Provider Business Mailing Address
First Line	:	2800 WELLFORD ST
Second Line	:	SUITE 100
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3176
Country	:	US
Telephone Number	:	540-361-1830
Fax Number	:	540-361-1829

Provider Business Practice Location Address
First Line	:	2800 WELLFORD ST
Second Line	:	SUITE 100
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3176
Country	:	US
Telephone Number	:	540-361-1830
Fax Number	:	540-361-1829

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	06/08/2020

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