Provider Demographics
NPI:1609848761
Name:SNYDER, MARK G (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:SNYDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1513 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2756
Mailing Address - Country:US
Mailing Address - Phone:414-476-1767
Mailing Address - Fax:
Practice Address - Street 1:700 PILGRIM PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2063
Practice Address - Country:US
Practice Address - Phone:262-796-2850
Practice Address - Fax:262-796-2851
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9980225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40402600Medicaid
WI40402600Medicaid