Provider Demographics
NPI:1023221728
Name:WASS, GARY LEROY (LMT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEROY
Last Name:WASS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 SW MULTNOMAH BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4072
Mailing Address - Country:US
Mailing Address - Phone:509-240-6989
Mailing Address - Fax:
Practice Address - Street 1:2929 SW MULTNOMAH BLVD STE 207
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4072
Practice Address - Country:US
Practice Address - Phone:509-240-6989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016138225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5633OtherOREGON STATE LISCENCE
WAMA00016138OtherSTATE LISCENCE NUMBER