Healthcare Provider Details

I. General information

NPI: 1770601387
Provider Name (Legal Business Name): MARK E CUNNINGHAM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35249 KENAI SPUR HWY STE C
SOLDOTNA AK
99669-7623
US

IV. Provider business mailing address

35249 KENAI SPUR HWY STE C
SOLDOTNA AK
99669-7623
US

V. Phone/Fax

Practice location:
  • Phone: 541-913-3089
  • Fax: 541-726-5515
Mailing address:
  • Phone: 907-420-0836
  • Fax: 907-420-0837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberPHYP2120
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: