Provider Demographics
NPI:1043444151
Name:NOBLE, MARK S (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:NOBLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:704-332-5206
Practice Address - Street 1:3623 LATROBE DR STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2117
Practice Address - Country:US
Practice Address - Phone:980-208-1704
Practice Address - Fax:704-926-1832
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-078472085R0204X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001424100Medicaid
FLP01028069OtherRAILROAD MEDICARE
FLP01000790OtherRAILROAD MEDICARE
FLY09JYOtherBCBS FL
FLP01000790OtherRAILROAD MEDICARE
FLP01028069OtherRAILROAD MEDICARE
FLY09JYOtherBCBS FL
FL593618240OtherTIN