Provider Demographics
NPI:1689967382
Name:MUNRO, MARK RANDALL (LMP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RANDALL
Last Name:MUNRO
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 E 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2531
Mailing Address - Country:US
Mailing Address - Phone:509-474-0213
Mailing Address - Fax:
Practice Address - Street 1:1303 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2531
Practice Address - Country:US
Practice Address - Phone:509-474-0213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60228318225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist