Provider Demographics
NPI:1912981861
Name:VESCIAL, MARK JOHN (MPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOHN
Last Name:VESCIAL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 132ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-7203
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:111 MARKET ST NE
Practice Address - Street 2:SUITE 108
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1008
Practice Address - Country:US
Practice Address - Phone:360-754-7085
Practice Address - Fax:360-754-3671
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009664225100000X
CA18486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0278102OtherL&I
WA195228OtherDEPT OF LABOR&INDUSTRIES
WA8421125Medicaid
WA0278102OtherL&I
WA8852284Medicare ID - Type Unspecified