Basic Information
Provider Information | |||||||||
NPI: | 1912436445 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | WILSON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16083 SW UPPER BOONES FERRY RD STE 300 | ||||||||
Address2: |   | ||||||||
City: | TIGARD | ||||||||
State: | OR | ||||||||
PostalCode: | 972247736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002198835 | ||||||||
FaxNumber: | 5036399699 | ||||||||
Practice Location | |||||||||
Address1: | 3121 E MADISON ST STE 201 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981124259 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063245389 | ||||||||
FaxNumber: | 2063245391 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2017 | ||||||||
LastUpdateDate: | 07/31/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60742902 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | G8968027 | 01 | WA | MEDICARE | OTHER | 1912436445 | 01 | WA | MEDICARE | OTHER |