Basic Information
| Provider Information | |||||||||
| NPI: | 1053995936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOSTRA | ||||||||
| FirstName: | MADISON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034436156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2911 TENNYSON AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974084693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034436156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2021 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.