Provider Demographics
NPI:1861471625
Name:ANTON, MARY ELLEN (PT ATC)
Entity Type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:ANTON
Suffix:
Gender:F
Credentials:PT ATC
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:FEDOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT ATC
Mailing Address - Street 1:6415 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-4121
Mailing Address - Country:US
Mailing Address - Phone:509-327-4867
Mailing Address - Fax:509-327-0542
Practice Address - Street 1:6415 N MONROE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4121
Practice Address - Country:US
Practice Address - Phone:509-327-4867
Practice Address - Fax:509-327-0542
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8507261Medicaid
WAGAB8871178Medicare PIN
WA8507261Medicaid