Provider Demographics
NPI:1275544983
Name:POFF, GERALD R (MPT)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:R
Last Name:POFF
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 E EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2213
Mailing Address - Country:US
Mailing Address - Phone:509-837-2528
Mailing Address - Fax:
Practice Address - Street 1:211 EUCLID RD.
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1160
Practice Address - Country:US
Practice Address - Phone:509-882-7888
Practice Address - Fax:509-882-6588
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2626POOtherBLUE CROSS BLUE SHIELD
WA8424681Medicaid
WA8854792Medicare ID - Type Unspecified
WA8424681Medicaid