Provider Demographics
NPI:1992443618
Name:FERRELL, MARK JORDAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JORDAN
Last Name:FERRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4031
Mailing Address - Country:US
Mailing Address - Phone:828-778-3440
Mailing Address - Fax:
Practice Address - Street 1:2904 ROSE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-4031
Practice Address - Country:US
Practice Address - Phone:828-778-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant