Provider Demographics
NPI:1699130427
Name:BOOTH, MARK (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOOTH
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 1:1101 ERIE BLVD E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1148
Mailing Address - Country:US
Mailing Address - Phone:315-474-0240
Mailing Address - Fax:315-474-1601
Practice Address - Street 1:18 WELLS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:NY
Practice Address - Zip Code:13026-8724
Practice Address - Country:US
Practice Address - Phone:315-364-3388
Practice Address - Fax:315-364-5254
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant