Provider Demographics
NPI:1336353762
Name:PEARSON, MARK (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50232 HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:HENNING
Mailing Address - State:MN
Mailing Address - Zip Code:56551-9325
Mailing Address - Country:US
Mailing Address - Phone:218-639-5356
Mailing Address - Fax:
Practice Address - Street 1:50232 HAVEN DR
Practice Address - Street 2:
Practice Address - City:HENNING
Practice Address - State:MN
Practice Address - Zip Code:56551-9325
Practice Address - Country:US
Practice Address - Phone:218-639-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant