Provider Demographics
NPI:1265078398
Name:FERGUSON, MARK ALLEN (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 HIDDEN FARM LN
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7493
Mailing Address - Country:US
Mailing Address - Phone:919-579-4679
Mailing Address - Fax:
Practice Address - Street 1:1221 BROAD ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-3602
Practice Address - Country:US
Practice Address - Phone:919-552-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP10692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist