Provider Demographics
NPI:1831340264
Name:BLANK, MARK ANDREW (DPT, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:BLANK
Suffix:
Gender:M
Credentials:DPT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2140
Mailing Address - Country:US
Mailing Address - Phone:561-649-0321
Mailing Address - Fax:561-649-3931
Practice Address - Street 1:1736 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2140
Practice Address - Country:US
Practice Address - Phone:561-649-0321
Practice Address - Fax:561-649-3931
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL25692255A2300X
FL27666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer