Basic Information
| Provider Information | |||||||||
| NPI: | 1982097689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURASSA | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 E REID RD | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484398835 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 WEISS ST | ||||||||
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| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
| FaxNumber: | 9893214948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2015 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502003302 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.