Provider Demographics
NPI:1063920965
Name:HIBBARD, MARK LAWRENCE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LAWRENCE
Last Name:HIBBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7791
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7791
Mailing Address - Country:US
Mailing Address - Phone:760-709-2122
Mailing Address - Fax:
Practice Address - Street 1:120 W PEARL AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-734-9129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-14
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer