Healthcare Provider Details

I. General information

NPI: 1003908906
Provider Name (Legal Business Name): MARK ELLIOT WURSTER M.S.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 SMITHFIELD AVE
LINCOLN RI
02865-3500
US

IV. Provider business mailing address

100 HIGHLAND AVE STE 305
PROVIDENCE RI
02906-2753
US

V. Phone/Fax

Practice location:
  • Phone: 401-722-0012
  • Fax: 401-722-0056
Mailing address:
  • Phone: 401-722-0012
  • Fax: 401-722-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number822
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7136
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: