Provider Demographics
NPI:1063629301
Name:ROMANICK, MARK ANDREW (PT, ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:ROMANICK
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 W FALLCREEK CT
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5256
Mailing Address - Country:US
Mailing Address - Phone:701-775-4731
Mailing Address - Fax:
Practice Address - Street 1:2509 W FALLCREEK CT
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5256
Practice Address - Country:US
Practice Address - Phone:701-775-4731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND386225100000X
MN5799225100000X
ND021-842255A2300X
MN13062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer