Provider Demographics
NPI:1467820274
Name:STICKLER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STICKLER
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 1:8362 TAMARACK VLG
Mailing Address - Street 2:SUITE 119-448
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3392
Mailing Address - Country:US
Mailing Address - Phone:651-739-7777
Mailing Address - Fax:
Practice Address - Street 1:9157 CAMBRIDGE RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4907
Practice Address - Country:US
Practice Address - Phone:651-739-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other