Basic Information
| Provider Information | |||||||||
| NPI: | 1508186669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 OLIVE WAY | ||||||||
| Address2: | SUITE 1011 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066234570 | ||||||||
| FaxNumber: | 2066234574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 03/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT06294 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 60628838 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1508186669 | 05 | WA | MEDICAID |