Provider Demographics
NPI:1316205487
Name:PETERSON, MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 WALKERS BEND RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4165
Mailing Address - Country:US
Mailing Address - Phone:423-743-1245
Mailing Address - Fax:423-743-2885
Practice Address - Street 1:800 S MOHAWK DR
Practice Address - Street 2:SUITE D
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-2124
Practice Address - Country:US
Practice Address - Phone:423-743-1245
Practice Address - Fax:423-743-2885
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000005441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist