Provider Demographics
NPI:1487433991
Name:STUTZMANN, MARK EDWARD JR (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:STUTZMANN
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 W OAK HILL DR
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-3908
Mailing Address - Country:US
Mailing Address - Phone:516-384-9965
Mailing Address - Fax:
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:516-384-9965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2024-05-09
Deactivation Date:2023-09-25
Deactivation Code:
Reactivation Date:2024-01-17
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY031347363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program