Provider Demographics
NPI:1174264717
Name:MOLDOVAN, IAN (LMT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:MOLDOVAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18055 SW TUALATIN VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97003-3953
Mailing Address - Country:US
Mailing Address - Phone:503-406-2020
Mailing Address - Fax:
Practice Address - Street 1:18055 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97003-3953
Practice Address - Country:US
Practice Address - Phone:503-406-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist