Provider Demographics
NPI:1043298086
Name:WAHLGREN, RICHARD C (M-PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:WAHLGREN
Suffix:
Gender:M
Credentials:M-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4013
Mailing Address - Country:US
Mailing Address - Phone:253-833-7750
Mailing Address - Fax:253-887-9804
Practice Address - Street 1:122 3RD ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4013
Practice Address - Country:US
Practice Address - Phone:253-833-7750
Practice Address - Fax:253-887-9804
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000072292251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5338WAOtherREGENCE
WAGAB15557OtherMEDICARE LEGACY
WA135296OtherLABOR & INDUSTRIES
WAP07026Medicare UPIN
WA135296OtherLABOR & INDUSTRIES