Provider Demographics
NPI:1902153125
Name:DSOUZA, MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DSOUZA
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Gender:M
Credentials:PA
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Mailing Address - Street 1:9801 DUPONT AVE S
Mailing Address - Street 2:STE 425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3873
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:952-567-6176
Practice Address - Street 1:10709 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5509
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:952-567-6156
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2020-09-15
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Provider Licenses
StateLicense IDTaxonomies
MN11170363A00000X
MDC04769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant