Provider Demographics
NPI:1740386077
Name:FEASLINE, MARK E (MSPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:FEASLINE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1803
Mailing Address - Country:US
Mailing Address - Phone:208-245-7634
Mailing Address - Fax:208-245-7070
Practice Address - Street 1:229 S 7TH ST
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1803
Practice Address - Country:US
Practice Address - Phone:208-245-7634
Practice Address - Fax:208-245-7070
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1879225100000X
IDPT1879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0212540OtherLABOR & INDUSTRY
ID807663800Medicaid
ID807663800Medicaid