Provider Demographics
NPI:1801811146
Name:LIMBACK, MARK ALLEN (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:LIMBACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:622 W MAPLE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6590
Mailing Address - Country:US
Mailing Address - Phone:505-327-4867
Mailing Address - Fax:505-327-5355
Practice Address - Street 1:622 W MAPLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6590
Practice Address - Country:US
Practice Address - Phone:505-327-4867
Practice Address - Fax:505-327-5355
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM94-PA29363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical