Basic Information
| Provider Information | |||||||||
| NPI: | 1659468585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARNHURST | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346098102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522775348 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 92 CYPRESS BLVD W | ||||||||
| Address2: | |||||||||
| City: | HOMOSASSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344464562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527654737 | ||||||||
| FaxNumber: | 3525036868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| 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 | 363A00000X | PA9101148 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA9101148 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 000887900 | 05 | FL | MEDICAID | Y06HB | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |