Provider Demographics
NPI:1386941904
Name:MOQUIN, MARK RAYMOND (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RAYMOND
Last Name:MOQUIN
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 1:205 SOUTH FRONT STREET
Mailing Address - Street 2:4TH FLOOR, BMA
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1619
Mailing Address - Country:US
Mailing Address - Phone:717-231-8555
Mailing Address - Fax:717-231-8568
Practice Address - Street 1:205 S FRONT ST
Practice Address - Street 2:4TH FLOOR, BMA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-231-8555
Practice Address - Fax:717-231-8568
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054787363A00000X
PAMA-054787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103144704Medicaid
PA208963Medicare PIN
PA103144704Medicaid
PA330296Medicare PIN