Provider Demographics
NPI:1811171861
Name:ANTHONY, MARK A
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:ANTHONY
Suffix:
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:P.O. BOX 333
Mailing Address - Street 2:
Mailing Address - City:BARNSDALL
Mailing Address - State:OK
Mailing Address - Zip Code:74002-0333
Mailing Address - Country:US
Mailing Address - Phone:918-857-6381
Mailing Address - Fax:918-847-3326
Practice Address - Street 1:544 MATHEWS
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-0544
Practice Address - Country:US
Practice Address - Phone:918-857-6381
Practice Address - Fax:918-847-3326
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK325225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant