Provider Demographics
NPI:1578721577
Name:WHEATON, MARK JOSEPH (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:WHEATON
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 1:449 RIVER RD APT 5
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4279
Mailing Address - Country:US
Mailing Address - Phone:207-240-5769
Mailing Address - Fax:
Practice Address - Street 1:449 RIVER RD APT 5
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4279
Practice Address - Country:US
Practice Address - Phone:207-240-5769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2516225200000X
NH0928225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant