Provider Demographics
NPI:1619204294
Name:MOORE, MARK WILLIAM (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
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Mailing Address - Street 1:223 PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:SAXONBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16056-2217
Mailing Address - Country:US
Mailing Address - Phone:724-352-9445
Mailing Address - Fax:724-352-9061
Practice Address - Street 1:223 PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:SAXONBURG
Practice Address - State:PA
Practice Address - Zip Code:16056-2217
Practice Address - Country:US
Practice Address - Phone:724-352-9445
Practice Address - Fax:724-352-9061
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PATE008140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant