Basic Information
| Provider Information | |||||||||
| NPI: | 1346432309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATEJA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPT/PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7301 PEAK DR | ||||||||
| Address2: | #150 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891289037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022569738 | ||||||||
| FaxNumber: | 7022425629 | ||||||||
| Practice Location | |||||||||
| Address1: | 3155 W CRAIG RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890320782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026392333 | ||||||||
| FaxNumber: | 7026392334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2154 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1346432309 | 05 | NV | MEDICAID |