Provider Demographics
NPI:1720165913
Name:WHITLEY, MARK A (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WHITLEY
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 1:23806 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9665
Mailing Address - Country:US
Mailing Address - Phone:509-868-7202
Mailing Address - Fax:
Practice Address - Street 1:23806 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9665
Practice Address - Country:US
Practice Address - Phone:509-868-7202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8345217Medicaid
WA1720165913Medicaid
WA1720165913Medicaid
WAG8921442Medicare PIN