Provider Demographics
NPI:1588692602
Name:ROMAN, MARK DAVID (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:ROMAN
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 1:10 KRUGER RD
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:MT
Mailing Address - Zip Code:59859-9271
Mailing Address - Country:US
Mailing Address - Phone:406-826-4800
Mailing Address - Fax:406-826-4811
Practice Address - Street 1:225 MARY WALLACE WAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-5054
Practice Address - Country:US
Practice Address - Phone:770-608-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291095100Medicaid