Provider Demographics
NPI:1437132115
Name:PETERSON, KRISTIN KAY (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KAY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:KAY
Other - Last Name:LAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1217 PLAZA BLVD STE E
Practice Address - Street 2:SUITE 130
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2682
Practice Address - Country:US
Practice Address - Phone:541-664-2800
Practice Address - Fax:541-664-0555
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0326297OtherWA L&I
OR182952Medicaid
ORP01582590OtherRR MEDICARE
WA0326284OtherWA L&I
ORP01582590OtherRR MEDICARE
OR114104Medicare ID - Type Unspecified