Basic Information
Provider Information | |||||||||
NPI: | 1982651352 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4024 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658084024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178853888 | ||||||||
FaxNumber: | 4178817638 | ||||||||
Practice Location | |||||||||
Address1: | 3801 S NATIONAL AVE | ||||||||
Address2: | WEST TOWER, SUITE 700 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658075210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178853888 | ||||||||
FaxNumber: | 4178817638 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2006 | ||||||||
LastUpdateDate: | 09/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2005004531 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 18942 | 01 | MO | COX HEALTH PLANS | OTHER | 502277007 | 05 | MO |   | MEDICAID | 0215422 | 01 | WA | DEPARTMENT OF LABOR WA | OTHER | Q42967 | 01 | MO | USPS (W/C) | OTHER | 0604585 | 01 | MO | UNITED HEALTHCARE | OTHER | 195811 | 01 | MO | ATHEM BLUE CROSS/SHIELD | OTHER | 23083 | 01 | MO | COX HEALTH PLANS UPI | OTHER |