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General NPI Number Information
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NPI Number | 1730478066
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Entity Type | Individual
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Provider Name | MARK ANDREW TIEDEMAN PHYSICAL THERAPIST
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Gender | Male
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Dates
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Enumeration Date | 04/07/2011
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Last Update Date | 04/07/2011
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Provider Practice Location Address
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Address Line | 5927 KANAN RD
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City | AGOURA HILLS
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State | CA
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Zip | 91301-1688
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Country | US
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Telephone | 818-889-0158
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Fax | 818-889-4708
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Provider Business Mailing Address
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Address Line | 5927 KANAN RD
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City | AGOURA HILLS
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State | CA
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Zip | 91301-1688
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Country | US
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Telephone | 818-889-0158
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Fax | 818-889-4708
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT27038
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License Number State | CA
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