Provider Demographics
NPI:1437130952
Name:EGBERT, LON MIGUEL (PT, ATC)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:MIGUEL
Last Name:EGBERT
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 EAGLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:ID
Mailing Address - Zip Code:83355-3340
Mailing Address - Country:US
Mailing Address - Phone:208-536-2135
Mailing Address - Fax:
Practice Address - Street 1:128 5TH AVE W
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1863
Practice Address - Country:US
Practice Address - Phone:208-324-3090
Practice Address - Fax:208-324-3093
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT6962OtherBLUE CROSS
ID000010140741OtherBLUE SHIELD
ID000010140741OtherBLUE SHIELD