Provider Demographics
NPI:1063758597
Name:WESTRA, MARK RAYMOND (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RAYMOND
Last Name:WESTRA
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:604 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31719-8300
Mailing Address - Country:US
Mailing Address - Phone:229-938-8072
Mailing Address - Fax:229-391-4585
Practice Address - Street 1:1610 JOHN ORR DR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3682
Practice Address - Country:US
Practice Address - Phone:229-391-4580
Practice Address - Fax:229-391-4585
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA2118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist