Basic Information
Provider Information | |||||||||
NPI: | 1205964939 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CROSS | ||||||||
FirstName: | MARK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 874 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FORTUNA | ||||||||
State: | CA | ||||||||
PostalCode: | 955401926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7077253334 | ||||||||
FaxNumber: | 7077252455 | ||||||||
Practice Location | |||||||||
Address1: | 2650 E FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911073439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6265772261 | ||||||||
FaxNumber: | 7077252455 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2007 | ||||||||
LastUpdateDate: | 09/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 19505 | CA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363AM0700X | 2322 | CO | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 19505 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 83821368 | 05 | CA |   | MEDICAID |