Provider Demographics
NPI:1982602827
Name:PLANTE, MARK STEPHEN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:PLANTE
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 1:381 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2340
Mailing Address - Country:US
Mailing Address - Phone:928-580-5769
Mailing Address - Fax:928-782-1019
Practice Address - Street 1:381 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2340
Practice Address - Country:US
Practice Address - Phone:928-580-5769
Practice Address - Fax:928-782-1019
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0460990OtherBLUE CROSS BLUE SHIELD ID
AZ690330Medicaid
AZAZ0460990OtherBLUE CROSS BLUE SHIELD ID