Provider Demographics
NPI:1205964939
Name:CROSS, MARK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8017
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:4723 W MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:CA
Practice Address - Zip Code:93434-1787
Practice Address - Country:US
Practice Address - Phone:805-361-8017
Practice Address - Fax:805-361-8097
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO2322363AM0700X
CA19505363AM0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83821368Medicaid
CA83821368Medicaid
Q78965Medicare UPIN