Provider Demographics
NPI:1285889154
Name:RICE, MARK NEAL (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:NEAL
Last Name:RICE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3576 PARKER BOULEVARD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008
Mailing Address - Country:US
Mailing Address - Phone:719-252-7102
Mailing Address - Fax:
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-252-7102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO2709363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5410910001Medicare NSC