Provider Demographics
NPI:1003971037
Name:POORBAUGH, KEITH (PT, SCD, OCS, FAAOMP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:POORBAUGH
Suffix:
Gender:M
Credentials:PT, SCD, OCS, FAAOMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 NORTH MERIDIAN PL
Mailing Address - Street 2:A
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7215
Mailing Address - Country:US
Mailing Address - Phone:907-631-4029
Mailing Address - Fax:907-631-4128
Practice Address - Street 1:984 N MERIDIAN PL
Practice Address - Street 2:# A
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7215
Practice Address - Country:US
Practice Address - Phone:907-631-4029
Practice Address - Fax:907-631-4128
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK160450Medicare ID - Type UnspecifiedMEDICARE #