Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | PT24624 | CA |
Y | 2251X0800X | Physical Therapist - Orthopedic | PT24624 | CA |
NPI | 1013070200 |
---|---|
Provider Name | Mark Eugene Wegener |
First Address | Lake Forest, CA 92630-2820 |
Second Address | Lake Forest, CA 92630-2820 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2006 |
Last Update Date | 24/05/2018 |