Provider Demographics
NPI:1437444130
Name:ANDERSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ANDERSON
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 1:4720 E COTTON GIN LOOP
Mailing Address - Street 2:STE 140
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-4823
Mailing Address - Country:US
Mailing Address - Phone:602-567-9881
Mailing Address - Fax:
Practice Address - Street 1:4720 E COTTON GIN LOOP
Practice Address - Street 2:STE 140
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-4823
Practice Address - Country:US
Practice Address - Phone:602-567-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7344A225200000X
WAP160981068225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant