Provider Demographics
NPI:1336295146
Name:STANG, TROY GLEN (MS, PT)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:GLEN
Last Name:STANG
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 S BURLINGTON BLVD # 474
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-3223
Mailing Address - Country:US
Mailing Address - Phone:360-424-5215
Mailing Address - Fax:
Practice Address - Street 1:803 S 15TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4514
Practice Address - Country:US
Practice Address - Phone:360-424-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084304Medicaid
WA7084304Medicaid