Provider Demographics
NPI:1093897613
Name:EGBERT, MICHAEL ANDREW (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:EGBERT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20910 SR 410 E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6302
Mailing Address - Country:US
Mailing Address - Phone:253-862-2575
Mailing Address - Fax:253-862-2675
Practice Address - Street 1:20910 SR 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6302
Practice Address - Country:US
Practice Address - Phone:253-862-2575
Practice Address - Fax:253-862-2675
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT5418225100000X
WAPT000054182251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8543712Medicaid
WA171896OtherL&I PROVIDER NO.
WA7126303Medicaid
WAEG4516OtherBLUE SHIELD PROV. NO.
WA246114OtherL&I
WAP00061737OtherMEDICARE RAILROAD
WA7421EGOtherBLUE SHILD BL
WAEG4516OtherBLUE SHIELD PROV. NO.
WA8543712Medicaid