Provider Demographics
NPI:1346785326
Name:BOMMERSBACH, TY A (DPT)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:A
Last Name:BOMMERSBACH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 SW CEDAR HILLS BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1415
Mailing Address - Country:US
Mailing Address - Phone:503-850-9950
Mailing Address - Fax:
Practice Address - Street 1:2695 SW CEDAR HILLS BLVD STE 140
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1415
Practice Address - Country:US
Practice Address - Phone:503-850-9950
Practice Address - Fax:866-252-2247
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist