Basic Information
| Provider Information | |||||||||
| NPI: | 1548314008 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MAIN | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2445 140TH AVE NE | ||||||||
| Address2: | SUITE B105 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256446328 | ||||||||
| FaxNumber: | 4256446295 | ||||||||
| Practice Location | |||||||||
| Address1: | 21907 64TH AVE W | ||||||||
| Address2: | SUITE #110 | ||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256735220 | ||||||||
| FaxNumber: | 4256731597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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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 | 225200000X | PL 60033988 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.