Provider Demographics
NPI:1922342377
Name:MERRELL, MARK ERIC (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ERIC
Last Name:MERRELL
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 1:2840 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7960
Mailing Address - Country:US
Mailing Address - Phone:208-593-6393
Mailing Address - Fax:208-593-6402
Practice Address - Street 1:2840 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7960
Practice Address - Country:US
Practice Address - Phone:208-593-6393
Practice Address - Fax:208-593-6402
Is Sole Proprietor?:No
Enumeration Date:2012-11-23
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDGPA-054363A00000X
IDPA-1054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant