MEDICARE: DR. MARK HENRY VANDER HULST DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT60840347	WA
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1417440033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK HENRY VANDER HULST DPT

Provider Business Mailing Address
First Line	:	1824 FRONT ST STE A
Second Line	:
City	:	LYNDEN
State	:	WA
Zip	:	98264-1729
Country	:	US
Telephone Number	:	360-354-0585
Fax Number	:	360-354-1098

Provider Business Practice Location Address
First Line	:	1824 FRONT ST STE A
Second Line	:
City	:	LYNDEN
State	:	WA
Zip	:	98264-1729
Country	:	US
Telephone Number	:	360-354-0585
Fax Number	:	360-354-1098

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2018
Last Update Date	:	12/01/2025

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