Basic Information
| Provider Information | |||||||||
| NPI: | 1518058031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEGANOFF | ||||||||
| FirstName: | DINA | ||||||||
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| Credential: | PHYSICAL THERAPIST A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 3180 NE 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986072407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603359033 | ||||||||
| FaxNumber: | 3603359035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 8260 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225100000X | 60695911 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01853434 | 01 | WA | RR MEDICARE | OTHER | 1518058031 | 05 | WA | MEDICAID |