Provider Demographics
NPI:1285748897
Name:MAZAK, MARK A (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MAZAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1345
Mailing Address - Country:US
Mailing Address - Phone:732-364-0515
Mailing Address - Fax:732-364-6006
Practice Address - Street 1:150 E KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1345
Practice Address - Country:US
Practice Address - Phone:732-364-0515
Practice Address - Fax:732-364-6006
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00083300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P73727Medicare UPIN
064801Medicare ID - Type Unspecified