Provider Demographics
NPI:1083690192
Name:GANTER, KRISTINA K W (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:K W
Last Name:GANTER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:K
Other - Last Name:WALTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:PO BOX 5541
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-0541
Mailing Address - Country:US
Mailing Address - Phone:541-284-2084
Mailing Address - Fax:541-485-1087
Practice Address - Street 1:1034 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3440
Practice Address - Country:US
Practice Address - Phone:541-284-2084
Practice Address - Fax:541-485-1087
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2023-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158091OtherPTAN
OR000135Medicaid
OR158091OtherPTAN