Provider Demographics
NPI:1285401356
Name:ROURKE, MAXWELL DYLAN (PTA)
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:DYLAN
Last Name:ROURKE
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 1:6714 BUCHANAN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MIFFLIN
Mailing Address - State:PA
Mailing Address - Zip Code:15122-2730
Mailing Address - Country:US
Mailing Address - Phone:412-651-0619
Mailing Address - Fax:
Practice Address - Street 1:100 9TH ST
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-3952
Practice Address - Country:US
Practice Address - Phone:412-675-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI005215225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant