Provider Demographics
NPI:1912912791
Name:COGLIANESE, MARK J (MPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:COGLIANESE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 GOLDEN WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5270
Mailing Address - Country:US
Mailing Address - Phone:084-031-5052
Mailing Address - Fax:083-596-1272
Practice Address - Street 1:217 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1621
Practice Address - Country:US
Practice Address - Phone:208-359-6127
Practice Address - Fax:208-359-6127
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1375225100000X
IDPT-2916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1912912791Medicaid
NV1912912791Medicaid