Provider Demographics
NPI:1902876931
Name:GELLASCH, MARK ALAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:GELLASCH
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2753 SANDPIPER RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-4516
Mailing Address - Country:US
Mailing Address - Phone:757-426-7700
Mailing Address - Fax:
Practice Address - Street 1:BRANCH MEDICAL CLINIC NORFOLK
Practice Address - Street 2:1721 TAUSSIG BLVD
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511
Practice Address - Country:US
Practice Address - Phone:757-314-6377
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110000034363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110000034OtherSTATE MEDICAL LICENCE
1003448OtherNATIONAL CERTIFICATION