Provider Demographics
NPI:1790900405
Name:CHISUM, MARK ALLEN (ATC LAT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:CHISUM
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 GENOA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-1707
Mailing Address - Country:US
Mailing Address - Phone:806-791-5178
Mailing Address - Fax:806-742-4265
Practice Address - Street 1:237 GENOA AVENUE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416
Practice Address - Country:US
Practice Address - Phone:806-742-5111
Practice Address - Fax:806-742-4265
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATO6922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2255A2300XMedicare UPIN