1134597404 NPI number — ALEXANDER WIRTA PT

Table of content: ALEXANDER WIRTA PT (NPI 1134597404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134597404 NPI number — ALEXANDER WIRTA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIRTA
Provider First Name:
ALEXANDER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134597404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16083 SW UPPER BOONES FERRY RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19017 120TH AVE NE BLDG 1
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
BOTHELL
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98011-9510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-489-3420
Provider Business Practice Location Address Fax Number:
425-489-3421
Provider Enumeration Date:
09/03/2015

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:  PT 60555817 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1134597404 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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