Provider Demographics
NPI:1013117662
Name:PHILLIPS, MARK A (PTA-01827)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PTA-01827
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1138 KELLER DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-1635
Mailing Address - Country:US
Mailing Address - Phone:419-632-9744
Mailing Address - Fax:
Practice Address - Street 1:1170 W MANSFIELD ST
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-8509
Practice Address - Country:US
Practice Address - Phone:419-562-9907
Practice Address - Fax:419-562-1962
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-01827225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant