Provider Demographics
NPI:1952380222
Name:PURCELL, MARK STEVEN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:PURCELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3017
Mailing Address - Country:US
Mailing Address - Phone:360-636-4360
Mailing Address - Fax:360-425-5250
Practice Address - Street 1:1118 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3017
Practice Address - Country:US
Practice Address - Phone:360-636-4360
Practice Address - Fax:360-425-5250
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6500 24408OtherRAILROAD MEDICARE NUMBER
WA0103-981OtherDEPARTMENT OF L & I NO.
WA182420OtherOMAP PROVIDER NUMBER
WA8413445Medicaid
WAPU0807OtherREGENCE PROVIDER NUMBER
WA6500 24408OtherRAILROAD MEDICARE NUMBER