Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT013618 | GA |
NPI | 1003302688 |
---|---|
Provider Name | Mark Andrew Stevens |
First Address | Chattanooga, TN 37421-2564 |
Second Address | Stone Mountain, GA 30087 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2018 |
Last Update Date | 20/08/2018 |