Provider Demographics
NPI:1407928344
Name:MOLINE, THOMAS DAVID (PT, MS,)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVID
Last Name:MOLINE
Suffix:
Gender:M
Credentials:PT, MS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1627 WOODS CT
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2915
Practice Address - Country:US
Practice Address - Phone:541-386-9511
Practice Address - Fax:866-860-8070
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007650225100000X
OR36492251X0800X
OR03649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR322858OtherPROVIDENCE HEALTH PLAN
ORJ5366-01OtherPACIFICSOURCE HEALTH PLAN
ORJ5366-01OtherPACIFICSOURCE HEALTH PLAN