Provider Demographics
NPI:1538191861
Name:MOUTY, MARK PATRICK (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:PATRICK
Last Name:MOUTY
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 1:751 OLD RICHARDSON HWY
Mailing Address - Street 2:STE # 200
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7813
Mailing Address - Country:US
Mailing Address - Phone:907-451-6561
Mailing Address - Fax:907-451-4847
Practice Address - Street 1:751 OLD RICHARDSON HWY
Practice Address - Street 2:STE # 200
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7813
Practice Address - Country:US
Practice Address - Phone:907-451-6561
Practice Address - Fax:907-451-4847
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK696363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK696OtherSTATE MEDICAL LICENSE
UTS49540Medicare UPIN