Provider Demographics
NPI:1396917431
Name:HOGAN, MARK R (LAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HOGAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3722
Mailing Address - Country:US
Mailing Address - Phone:406-546-8327
Mailing Address - Fax:
Practice Address - Street 1:1004 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7909
Practice Address - Country:US
Practice Address - Phone:406-546-8327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT226171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist