Provider Demographics
NPI:1831678929
Name:MENNING, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MENNING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 TERAVISTA CLUB DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1525
Mailing Address - Country:US
Mailing Address - Phone:512-310-3700
Mailing Address - Fax:
Practice Address - Street 1:4105 TERAVISTA CLUB DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1525
Practice Address - Country:US
Practice Address - Phone:512-310-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2042075225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant