Provider Demographics
NPI:1558576082
Name:SUTTON, MARY JEAN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:SUTTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12257 BUSINESS PARK DR STE 11
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-3336
Mailing Address - Country:US
Mailing Address - Phone:530-587-9355
Mailing Address - Fax:530-587-3901
Practice Address - Street 1:12257 BUSINESS PARK DR STE 11
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-3336
Practice Address - Country:US
Practice Address - Phone:530-587-9355
Practice Address - Fax:530-587-3901
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT74970Medicare ID - Type UnspecifiedPHYSICAL THERAPIST