Provider Demographics
NPI:1699512368
Name:IKAN, MHARK JOSEPH PAPA
Entity type:Individual
Prefix:
First Name:MHARK JOSEPH
Middle Name:PAPA
Last Name:IKAN
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 1:9320 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1050
Mailing Address - Country:US
Mailing Address - Phone:929-701-2709
Mailing Address - Fax:
Practice Address - Street 1:9320 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1050
Practice Address - Country:US
Practice Address - Phone:929-701-2709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist