Provider Demographics
NPI:1922303288
Name:WARD, MARK ANDREW (LMP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:WARD
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20912 MICHIGAN HILL RD SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579-9014
Mailing Address - Country:US
Mailing Address - Phone:360-824-0442
Mailing Address - Fax:
Practice Address - Street 1:117 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2564
Practice Address - Country:US
Practice Address - Phone:360-427-3189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60180775174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist