Provider Demographics
NPI:1528121274
Name:WERKHOVEN, MARCO A (PT)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:A
Last Name:WERKHOVEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 CLOUD DANCE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2591
Mailing Address - Country:US
Mailing Address - Phone:505-438-2960
Mailing Address - Fax:505-438-2960
Practice Address - Street 1:4309 CLOUD DANCE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2591
Practice Address - Country:US
Practice Address - Phone:505-438-2960
Practice Address - Fax:505-438-2960
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1580225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000D3744Medicaid
NM03386503Medicaid