Individual
MARK ROBERT PEACOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
6003 SE 136TH AVE, PORTLAND, OR 97236-4567
(971) 978-1268
Mailing address
4560 SE INTERNATIONAL WAY STE 100, MILWAUKIE, OR 97222-4628
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
9978
OR
Other
Enumeration date
08/18/2021
Last updated
08/18/2021
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