Healthcare Provider Details

I. General information

NPI: 1043596679
Provider Name (Legal Business Name): ANTHONY MICHAEL MARK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 TERRY AVE MAILSTOP: X2-SM
SEATTLE WA
98101-2735
US

IV. Provider business mailing address

1201 TERRY AVE MAILSTOP: X2-SM
SEATTLE WA
98101-2735
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-7528
  • Fax: 206-223-7577
Mailing address:
  • Phone: 206-223-7528
  • Fax: 206-223-7577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT60228289
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: