Provider Demographics
NPI:1659381069
Name:BOUMA, MARK J (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BOUMA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
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Mailing Address - Street 1:1309 HARBOR AVE SW
Mailing Address - Street 2:STE A
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-1784
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:7650 SE 27TH ST
Practice Address - Street 2:SUITE 112
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3060
Practice Address - Country:US
Practice Address - Phone:206-230-8320
Practice Address - Fax:206-230-8315
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8905387Medicare PIN