Provider Demographics
NPI:1053801886
Name:SIEBE, MARK LEON (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEON
Last Name:SIEBE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1046 WESTON CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2404
Mailing Address - Country:US
Mailing Address - Phone:615-630-2250
Mailing Address - Fax:615-630-2250
Practice Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:650 JOEL DR
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN3649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant