Provider Demographics
NPI:1598185415
Name:SIPES, MARK (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SIPES
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 1:301 ADOBE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:KENWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:95452-9047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 ADOBE CANYON RD
Practice Address - Street 2:
Practice Address - City:KENWOOD
Practice Address - State:CA
Practice Address - Zip Code:95452-9047
Practice Address - Country:US
Practice Address - Phone:707-362-0743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT5766225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant