Provider Demographics
NPI:1104638105
Name:LOCKETT, MARK ANTHONY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:LOCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6432 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-9503
Mailing Address - Country:US
Mailing Address - Phone:816-213-4917
Mailing Address - Fax:
Practice Address - Street 1:6432 CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-9503
Practice Address - Country:US
Practice Address - Phone:816-213-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-25
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000035030777172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty