Provider Demographics
NPI:1952896532
Name:ANDERSEN-NISSEN, MARK DAVID
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:ANDERSEN-NISSEN
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 1:3601 S PEARL ST UNIT 200
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3894
Mailing Address - Country:US
Mailing Address - Phone:303-757-1554
Mailing Address - Fax:
Practice Address - Street 1:3601 S PEARL ST UNIT 200
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3894
Practice Address - Country:US
Practice Address - Phone:303-757-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist