Provider Demographics
NPI:1548644891
Name:DUYCK, MARK GERARD (PTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:GERARD
Last Name:DUYCK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:MARC
Other - Middle Name:GERARD
Other - Last Name:DUYCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:17360 HOLY NAMES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-5133
Mailing Address - Country:US
Mailing Address - Phone:503-675-2449
Mailing Address - Fax:
Practice Address - Street 1:17360 HOLY NAMES DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-5133
Practice Address - Country:US
Practice Address - Phone:503-675-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant