MEDICARE: MARK ELNO ARCHAMBAULT 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	363AM0700X	Medical Physician Assistant	0010-01083	NC

General Provider Information

NPI Number	:	1881825917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ELNO ARCHAMBAULT PA-C

Provider Business Mailing Address
First Line	:	DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES
Second Line	:	MEDICAL CENTER BLVD
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-1006
Country	:	US
Telephone Number	:	336-716-2028
Fax Number	:	336-716-4432

Provider Business Practice Location Address
First Line	:	DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES
Second Line	:	MEDICAL CENTER BLVD
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-1006
Country	:	US
Telephone Number	:	336-716-2028
Fax Number	:	336-716-4432

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

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	08/06/2009

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