Provider Demographics
NPI:1750480588
Name:D'ANZA, MARK JOSEPH (ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:D'ANZA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11181 MEZZANA ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3402
Mailing Address - Country:US
Mailing Address - Phone:702-682-2453
Mailing Address - Fax:
Practice Address - Street 1:11181 MEZZANA ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89141-3402
Practice Address - Country:US
Practice Address - Phone:702-682-2453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05061292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer