Provider Demographics
NPI:1083159537
Name:KANG, MARK (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14712 CARONA DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-7411
Mailing Address - Country:US
Mailing Address - Phone:301-526-6301
Mailing Address - Fax:
Practice Address - Street 1:8401 COLESVILLE RD
Practice Address - Street 2:SUITE 50
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3312
Practice Address - Country:US
Practice Address - Phone:301-588-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00004892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer