Provider Demographics
NPI:1043660335
Name:WOOD, EDWIN JON (LMT)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:JON
Last Name:WOOD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:EDWIN
Other - Middle Name:JON
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1403 SE 37TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5166
Mailing Address - Country:US
Mailing Address - Phone:503-757-3475
Mailing Address - Fax:503-281-0008
Practice Address - Street 1:1939 NE BROADWAY ST
Practice Address - Street 2:STE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1583
Practice Address - Country:US
Practice Address - Phone:503-757-3475
Practice Address - Fax:503-281-0008
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10626225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist