Provider Demographics
NPI:1407488562
Name:TENTATIVA, MARC CONRAD TY (PT)
Entity Type:Individual
Prefix:
First Name:MARC CONRAD
Middle Name:TY
Last Name:TENTATIVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-689-5534
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:3305 N SWAN RD STE 115
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1273
Practice Address - Country:US
Practice Address - Phone:520-321-0204
Practice Address - Fax:520-321-0495
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1328172225100000X
AZCP014934T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist