Provider Demographics
NPI:1538239272
Name:MCCONNELL, MARK WILLIAM (PAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:1450 SCALP AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3374
Practice Address - Country:US
Practice Address - Phone:814-269-7138
Practice Address - Fax:814-269-5070
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA001871L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841250OtherBS
P66328Medicare UPIN