Provider Demographics
NPI:1780682559
Name:DESANTIS, MARK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 NATURE PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-6960
Mailing Address - Country:US
Mailing Address - Phone:724-836-5540
Mailing Address - Fax:724-836-5548
Practice Address - Street 1:118 NATURE PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-6960
Practice Address - Country:US
Practice Address - Phone:724-836-5540
Practice Address - Fax:724-836-5548
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000273L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA331535LC7Medicare PIN
PAS28604Medicare UPIN