Basic Information
| Provider Information | |||||||||
| NPI: | 1972581114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARIANI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3124 S 19TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534597000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3124 S 19TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534597000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | A85025 | CA | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 207Q00000X | A85025 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | A85025 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | MD00046384 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | MD00046384 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 2081S0010X | MD00046384 | WA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 204C00000X | MD00046384 | WA | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
No ID Information.