Provider Demographics
NPI:1295989366
Name:BRONK, MARK JOSEPH (MARK BRONK, LMP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:BRONK
Suffix:
Gender:M
Credentials:MARK BRONK, LMP
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:JOSEPH
Other - Last Name:BRONK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MARL BRONK, LMP
Mailing Address - Street 1:2615 PERTH COURT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1505
Mailing Address - Country:US
Mailing Address - Phone:360-561-6412
Mailing Address - Fax:
Practice Address - Street 1:2615 PERTH CT SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-6642
Practice Address - Country:US
Practice Address - Phone:360-561-6412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-15
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015226174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist