The holder whose full name is Slack, Mark Raymond,come from Reston VA,hold the Temporary MD Permit license(NO.99026121A) which status is Superceded.
| Name | Slack, Mark Raymond |
|---|---|
| License Number | 99026121A |
| License Type | Temporary MD Permit |
| License Status | Superceded |
| City | Reston |
| State | VA |