Individual
MARK DEFAZIO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
185 HARRISON AVE, BOSTON, MA 02111-1804
(617) 636-5632
Mailing address
39 CHIPMAN ST, MEDFORD, MA 02155-4058
(781) 535-8636
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
9532
MA
Other
Enumeration date
03/16/2020
Last updated
03/16/2020
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