MEDICARE: MR. MARK ANTHONY WHITE JR. LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA60141244	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA 60141244	OTHER	WA	LMP, LICENSED MASSAGE PRACTICTIONER

General Provider Information

NPI Number	:	1013270552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ANTHONY WHITE JR. LMP

Provider Business Mailing Address
First Line	:	2220 N TRUMPETER DR
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-8968
Country	:	US
Telephone Number	:	425-244-1498
Fax Number	:

Provider Business Practice Location Address
First Line	:	2220 N TRUMPETER DR
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-8968
Country	:	US
Telephone Number	:	425-244-1498
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	06/20/2012

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