Provider Demographics
NPI:1528167277
Name:KNOWLES, MARK ANDREW (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:KNOWLES
Suffix:
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 1:457 GAFFNEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1834
Mailing Address - Country:US
Mailing Address - Phone:315-779-2273
Mailing Address - Fax:
Practice Address - Street 1:457 GAFFNEY DRIVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1834
Practice Address - Country:US
Practice Address - Phone:315-779-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY1605-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS54079Medicare UPIN