Provider Demographics
NPI:1104682178
Name:DUCKWORTH, MARK EDWARD (PTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:DUCKWORTH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 E OSBORN RD APT 129W
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-7433
Mailing Address - Country:US
Mailing Address - Phone:480-955-7297
Mailing Address - Fax:
Practice Address - Street 1:7701 E OSBORN RD APT 129W
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-7433
Practice Address - Country:US
Practice Address - Phone:480-955-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ000181225200000X
AZPTA-000181225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant