Provider Demographics
NPI:1063588044
Name:MARKIEWITZ, MARY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:MARKIEWITZ
Suffix:
Gender:F
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 1:2290 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2929
Mailing Address - Country:US
Mailing Address - Phone:707-643-5785
Mailing Address - Fax:707-643-8190
Practice Address - Street 1:1020 29TH ST
Practice Address - Street 2:SUITE 570A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5125
Practice Address - Country:US
Practice Address - Phone:916-733-3792
Practice Address - Fax:916-733-3805
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18413363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18413OtherPHYSICIAN ASSISTANT
MM1501483OtherDEA
CAPA18413OtherPHYSICIAN ASSISTANT