Provider Demographics
NPI:1962467746
Name:STACK, MARK A (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:STACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 MAKAWAO AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9465
Mailing Address - Country:US
Mailing Address - Phone:808-572-7790
Mailing Address - Fax:808-573-4721
Practice Address - Street 1:1043 MAKAWAO AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9465
Practice Address - Country:US
Practice Address - Phone:808-572-7790
Practice Address - Fax:808-573-4721
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-1242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1866663OtherUHA
HI24461708Medicaid
HI24461709Medicaid
HI194058OtherHMN
HI194058OtherHMN