Provider Demographics
NPI:1255950127
Name:CAGLE, MARK DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:CAGLE
Suffix:
Gender:M
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 1:1847 W HEATHERBRAE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4764
Mailing Address - Country:US
Mailing Address - Phone:602-274-2100
Mailing Address - Fax:602-535-3166
Practice Address - Street 1:5140 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7915
Practice Address - Country:US
Practice Address - Phone:602-207-8400
Practice Address - Fax:602-535-3166
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8078363A00000X, 363AM0700X
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8078OtherPHYSICIAN ASSISTANT BOARD