Basic Information
| Provider Information | |||||||||
| NPI: | 1568915023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LERMA | ||||||||
| FirstName: | KEEGAN | ||||||||
| MiddleName: | KM | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 685 36TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035408701 | ||||||||
| FaxNumber: | 5033718772 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 NW 4TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973304806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416024423 | ||||||||
| FaxNumber: | 5417547544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2016 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 61872 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.