MEDICARE: MR. MARK EDWARD DEYSHER MPT, OCS

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
2	225100000X	Physical Therapist	0010240	CO

General Provider Information

NPI Number	:	1467449843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK EDWARD DEYSHER MPT, OCS

Provider Business Mailing Address
First Line	:	151 WEST LAKE STREET
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-8031
Country	:	US
Telephone Number	:	970-491-1719
Fax Number	:	970-491-5306

Provider Business Practice Location Address
First Line	:	151 WEST LAKE STREET
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-8031
Country	:	US
Telephone Number	:	970-491-1719
Fax Number	:	970-491-5306

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/29/2019

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