1437132115 NPI number — KRISTIN KAY PETERSON PHYSICAL THERAPIST

Table of content: KRISTIN KAY PETERSON PHYSICAL THERAPIST (NPI 1437132115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437132115 NPI number — KRISTIN KAY PETERSON PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
KRISTIN
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAIR
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437132115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2016
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:
1217 PLAZA BLVD STE E
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
CENTRAL POINT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97502-2682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-664-2800
Provider Business Practice Location Address Fax Number:
541-664-0555
Provider Enumeration Date:
11/28/2005

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:  4473 , 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)

  • Identifier: 0326297 . This is a "WA L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 182952 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01582590 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 0326284 . This is a "WA L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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