Provider Demographics
NPI:1063785681
Name:GANEY, MARK DOUGLAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:GANEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1705 W KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-9582
Mailing Address - Country:US
Mailing Address - Phone:318-355-1373
Mailing Address - Fax:
Practice Address - Street 1:310 W MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-4202
Practice Address - Country:US
Practice Address - Phone:318-513-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312368363A00000X
TXPA09803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant