Provider Demographics
NPI:1063427904
Name:LOVELESS, MARK M (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:LOVELESS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:LOVELESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-7081
Mailing Address - Fax:
Practice Address - Street 1:1134 N 500 W
Practice Address - Street 2:#100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3383
Practice Address - Country:US
Practice Address - Phone:801-357-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53699191206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063390Medicare PIN