Provider Demographics
NPI:1871920132
Name:WOLFE, MARK T (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 BREEZEPORT WAY
Mailing Address - Street 2:APT 105
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1080
Mailing Address - Country:US
Mailing Address - Phone:484-883-4242
Mailing Address - Fax:
Practice Address - Street 1:3906 BREEZEPORT WAY
Practice Address - Street 2:APT 105
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1080
Practice Address - Country:US
Practice Address - Phone:484-883-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0126001906207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine