Provider Demographics
NPI:1750433918
Name:BRINKERHOFF, MARK ZELLER II
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ZELLER
Last Name:BRINKERHOFF
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 YELLOW CREEK RD
Mailing Address - Street 2:STE. D
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5200
Mailing Address - Country:US
Mailing Address - Phone:307-783-8068
Mailing Address - Fax:307-783-8073
Practice Address - Street 1:170 YELLOW CREEK RD
Practice Address - Street 2:STE. D
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5200
Practice Address - Country:US
Practice Address - Phone:307-783-8068
Practice Address - Fax:307-783-8073
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW307-852Medicare ID - Type Unspecified