Provider Demographics
NPI:1376854992
Name:KOOISTRA, ORION LAMBERT (DPT)
Entity Type:Individual
Prefix:
First Name:ORION
Middle Name:LAMBERT
Last Name:KOOISTRA
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 1:3942 NE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1236
Mailing Address - Country:US
Mailing Address - Phone:503-334-9799
Mailing Address - Fax:
Practice Address - Street 1:3942 NE 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1236
Practice Address - Country:US
Practice Address - Phone:503-334-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist