Provider Demographics
NPI:1992680532
Name:WANNER, MARK ALAN (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:WANNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 PALM COAST PKWY NE
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3805
Mailing Address - Country:US
Mailing Address - Phone:386-446-4101
Mailing Address - Fax:386-447-2161
Practice Address - Street 1:360 PALM COAST PKWY NE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3805
Practice Address - Country:US
Practice Address - Phone:386-446-4101
Practice Address - Fax:386-447-2161
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT43131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT43131OtherLICENSE