Healthcare Provider Details

I. General information

NPI: 1871049981
Provider Name (Legal Business Name): MARK SEXTON ATC, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3534 BROOKLYN AVE
FORT WAYNE IN
46809
US

IV. Provider business mailing address

4251 LAHMEYER RD
FORT WAYNE IN
46815-5676
US

V. Phone/Fax

Practice location:
  • Phone: 260-478-5230
  • Fax:
Mailing address:
  • Phone: 260-432-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002423A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05012905A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: