Provider Demographics
NPI:1104898758
Name:GESLAK, MARK JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:GESLAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4855 ENCANTO CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5618
Mailing Address - Country:US
Mailing Address - Phone:210-545-7324
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:MCHE-QD
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-916-2460
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA04593363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical