Provider Demographics
NPI:1992073647
Name:PETTUS, MARK NOEL (RPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:NOEL
Last Name:PETTUS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14631 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2244
Mailing Address - Country:US
Mailing Address - Phone:913-486-2207
Mailing Address - Fax:913-897-0248
Practice Address - Street 1:14631 FLOYD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-2244
Practice Address - Country:US
Practice Address - Phone:913-486-2207
Practice Address - Fax:913-897-0248
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist