Provider Demographics
NPI:1881825917
Name:ARCHAMBAULT, MARK ELNO (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ELNO
Last Name:ARCHAMBAULT
Suffix:
Gender:M
Credentials:PA-C
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES
Mailing Address - Street 2:MEDICAL CENTER BLVD
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1006
Mailing Address - Country:US
Mailing Address - Phone:336-716-2028
Mailing Address - Fax:336-716-4432
Practice Address - Street 1:DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES
Practice Address - Street 2:MEDICAL CENTER BLVD
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1006
Practice Address - Country:US
Practice Address - Phone:336-716-2028
Practice Address - Fax:336-716-4432
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-01083363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical