Provider Demographics
NPI:1104250455
Name:WILES, MARK DAVID (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:WILES
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2122 HEALTH DR SW STE 133
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-5950
Practice Address - Fax:616-252-5956
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2018-03-17
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIW420585135837OtherDRIVERS LICENSE
MI5601006792OtherMICHIGAN LICENSE