Provider Demographics
NPI:1801876214
Name:DE LA LAMA, MARK CHARLES (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:CHARLES
Last Name:DE LA LAMA
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:6550 N 40TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-1206
Mailing Address - Country:US
Mailing Address - Phone:623-322-5842
Mailing Address - Fax:
Practice Address - Street 1:4660 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-3718
Practice Address - Country:US
Practice Address - Phone:602-442-4500
Practice Address - Fax:602-442-4505
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3073363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical