Provider Demographics
NPI:1760890487
Name:PLANK, JONATHAN (AT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PLANK
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 S. LOCUST STE. 5
Mailing Address - Street 2:SOUTHWEST SPORT AND SPINE CENTER, INC
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-9998
Mailing Address - Country:US
Mailing Address - Phone:575-522-0766
Mailing Address - Fax:
Practice Address - Street 1:2404 S LOCUST ST STE 5
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5789
Practice Address - Country:US
Practice Address - Phone:575-522-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer