Provider Demographics
NPI:1588316772
Name:SNYDER, MARK CLIFFORD (PTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:CLIFFORD
Last Name:SNYDER
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 1:29145 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-4625
Mailing Address - Country:US
Mailing Address - Phone:952-412-5808
Mailing Address - Fax:
Practice Address - Street 1:11421 OLD GLENN HWY STE 101
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7783
Practice Address - Country:US
Practice Address - Phone:907-622-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0011476225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant