Provider Demographics
NPI:1699886614
Name:STEPHAN, MARK PATRICK (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:PATRICK
Last Name:STEPHAN
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 1:55 SPINDRIFT DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7800
Mailing Address - Country:US
Mailing Address - Phone:716-447-6310
Mailing Address - Fax:716-775-6288
Practice Address - Street 1:55 SPINDRIFT DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7800
Practice Address - Country:US
Practice Address - Phone:716-447-6310
Practice Address - Fax:716-775-6288
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010867363AS0400X
10867363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03076359Medicaid
NYQ61885Medicare UPIN
NYPA1245Medicare PIN