Provider Demographics
NPI:1760422042
Name:TASBER, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TASBER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901
Mailing Address - Country:US
Mailing Address - Phone:607-648-8052
Mailing Address - Fax:
Practice Address - Street 1:2663 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WHITNEY POINT
Practice Address - State:NY
Practice Address - Zip Code:13862
Practice Address - Country:US
Practice Address - Phone:607-692-4420
Practice Address - Fax:607-692-4415
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02692744Medicaid
NY02692744Medicaid