Healthcare Provider Details

I. General information

NPI: 1750480588
Provider Name (Legal Business Name): MARK JOSEPH D'ANZA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11181 MEZZANA ST
LAS VEGAS NV
89141-3402
US

IV. Provider business mailing address

11181 MEZZANA ST
LAS VEGAS NV
89141-3402
US

V. Phone/Fax

Practice location:
  • Phone: 702-682-2453
  • Fax:
Mailing address:
  • Phone: 702-682-2453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0506129
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: