Provider Demographics
NPI:1174096630
Name:AVENA, MARK SAYER
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SAYER
Last Name:AVENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17614 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99016-8532
Mailing Address - Country:US
Mailing Address - Phone:509-499-4931
Mailing Address - Fax:
Practice Address - Street 1:17614 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-8532
Practice Address - Country:US
Practice Address - Phone:509-499-4931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty