Provider Demographics
NPI:1275594756
Name:TULENKO, MARK WAGNER (MPT OCS CSCS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WAGNER
Last Name:TULENKO
Suffix:
Gender:M
Credentials:MPT OCS CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 INCARNATION DR
Mailing Address - Street 2:ATLANTIC SPORTS AND REHAB STE 101
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901
Mailing Address - Country:US
Mailing Address - Phone:434-978-4915
Mailing Address - Fax:434-978-7194
Practice Address - Street 1:1410 INCARNATION DR
Practice Address - Street 2:ATLANTIC SPORTS AND REHAB STE 101
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901
Practice Address - Country:US
Practice Address - Phone:434-978-4915
Practice Address - Fax:434-978-7194
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2305004631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
496631Medicare ID - Type Unspecified