Basic Information
| Provider Information | |||||||||
| NPI: | 1558640508 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ROBINSON | ||||||||
| FirstName: | WYATT | ||||||||
| MiddleName: | JON | ||||||||
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| 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: | 19017 120TH AVE NE BLDG 1 | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980119510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254893420 | ||||||||
| FaxNumber: | 4254893421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 11/12/2012 | ||||||||
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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 | PT60229384 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P1021705 | 01 | WA | RR MEDICARE | OTHER | 1558640508 | 05 | WA | MEDICAID |