Provider Demographics
NPI:1457475253
Name:RUPERT, MARK D (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:RUPERT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-7631
Mailing Address - Country:US
Mailing Address - Phone:570-275-5950
Mailing Address - Fax:
Practice Address - Street 1:101 LEADER DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1942
Practice Address - Country:US
Practice Address - Phone:570-323-3758
Practice Address - Fax:570-322-2379
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE000937L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant