Provider Demographics
NPI:1487728531
Name:SHOEMAKER, MARK A (PA-C,SA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SHOEMAKER
Suffix:
Gender:M
Credentials:PA-C,SA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:23671 SAINT FRANCIS BLVD NW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070-9802
Mailing Address - Country:US
Mailing Address - Phone:763-753-8724
Mailing Address - Fax:763-753-8725
Practice Address - Street 1:23671 SAINT FRANCIS BLVD NW
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-9802
Practice Address - Country:US
Practice Address - Phone:763-753-8724
Practice Address - Fax:763-753-8725
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN8822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR56499Medicare UPIN