Basic Information
| Provider Information | |||||||||
| NPI: | 1861711020 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PAKULAT | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606336035 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15004 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921283491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606336035 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2010 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology | 2251N0400X | 36753 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No ID Information.