Provider Demographics
NPI:1134484603
Name:LOMMEN, CODY (PT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LOMMEN
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:5955 SHOREVIEW LN N
Practice Address - Street 2:STE. 100
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-3981
Practice Address - Country:US
Practice Address - Phone:503-463-4221
Practice Address - Fax:503-463-4522
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA500647601Medicaid
WA500647601Medicaid