Provider Demographics
NPI:1467444547
Name:AUGUSTINE, MARK NOLAN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NOLAN
Last Name:AUGUSTINE
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 1:1138 MONTAGUE ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-2814
Mailing Address - Country:US
Mailing Address - Phone:757-284-6755
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT00000052112251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3658398Medicare ID - Type Unspecified