1649725441 NPI number — ANNA JORDAN KOMER PT, DPT, OLS

Table of content: ANNA JORDAN KOMER PT, DPT, OLS (NPI 1649725441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649725441 NPI number — ANNA JORDAN KOMER PT, DPT, OLS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMER
Provider First Name:
ANNA
Provider Middle Name:
JORDAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, OLS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WETZEL
Provider Other First Name:
ANNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, OLS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649725441
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 SW 1ST AVE.
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-222-1955
Provider Business Mailing Address Fax Number:
503-222-1485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 SW 1ST AVE.
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-222-1955
Provider Business Practice Location Address Fax Number:
503-222-1485
Provider Enumeration Date:
08/22/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  61766 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 61766 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)