Provider Demographics
NPI:1467212795
Name:COCKRELL, MICHAEL LOGAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOGAN
Last Name:COCKRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15686 SW PLEASANTVIEW CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-1292
Mailing Address - Country:US
Mailing Address - Phone:530-260-0142
Mailing Address - Fax:
Practice Address - Street 1:15000 SW BARROWS RD STE 201
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-8778
Practice Address - Country:US
Practice Address - Phone:971-930-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist