MEDICARE: MARK LOSTRACCO D.P.T

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	225100000X	Physical Therapist	11376	AZ
2	225100000X	Physical Therapist	1237856	TX

General Provider Information

NPI Number	:	1548690837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LOSTRACCO D.P.T

Provider Business Mailing Address
First Line	:	1075 S IDAHO RD
Second Line	:
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85119-6496
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 S IDAHO RD
Second Line	:
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85119-6496
Country	:	US
Telephone Number	:	480-983-0877
Fax Number	:

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

Provider Enumeration Date	:	11/22/2013
Last Update Date	:	01/22/2015

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