Basic Information
| Provider Information | |||||||||
| NPI: | 1639155237 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VANDE POL | ||||||||
| FirstName: | PHILIP | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| 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: | 12/16/2005 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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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 | 4927 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT00010802 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1639155237 | 05 | WA | MEDICAID | 8501348 | 05 | WA | MEDICAID | 278011 | 05 | OR | MEDICAID |