Basic Information
| Provider Information | |||||||||
| NPI: | 1275657355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAGGE | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.T., O.C.S., | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 GRANT RD | ||||||||
| Address2: | STE B27 | ||||||||
| City: | EAST WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988027715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098842992 | ||||||||
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| Practice Location | |||||||||
| Address1: | 230 GRANT ROAD, SUITE B27 | ||||||||
| Address2: | |||||||||
| City: | EAST WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098841437 | ||||||||
| FaxNumber: | 5098842811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00005726 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7052665 | 05 | WA | MEDICAID |