Provider Demographics
NPI:1740386077
Name:FEASLINE, MARK E (MSPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:FEASLINE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 N LAKEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-664-8194
Mailing Address - Fax:208-667-1847
Practice Address - Street 1:1101 E POLSTON AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-773-8111
Practice Address - Fax:208-773-8385
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMPT-1879174400000X
IDPT1879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0212540OtherLABOR & INDUSTRY
ID807663800Medicaid
ID807663800Medicaid