Basic Information
| Provider Information | |||||||||
| NPI: | 1043444151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOBLE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 221249 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282221249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043321291 | ||||||||
| FaxNumber: | 7043325206 | ||||||||
| Practice Location | |||||||||
| Address1: | 3623 LATROBE DR STE 216 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282112117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9802081704 | ||||||||
| FaxNumber: | 7049261832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2009 | ||||||||
| LastUpdateDate: | 09/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 0010-07847 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 363A00000X | 0010-07847 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 001424100 | 05 | FL | MEDICAID | P01028069 | 01 | FL | RAILROAD MEDICARE | OTHER | P01000790 | 01 | FL | RAILROAD MEDICARE | OTHER | Y09JY | 01 | FL | BCBS FL | OTHER |