Provider Demographics
NPI:1508330531
Name:LANDIS, MARK (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LANDIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 N QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17315-1214
Mailing Address - Country:US
Mailing Address - Phone:717-841-4313
Mailing Address - Fax:
Practice Address - Street 1:970 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3430
Practice Address - Country:US
Practice Address - Phone:717-845-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004998225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant