Provider Demographics
NPI:1477519874
Name:AKERS, GLEN RAYMOND (PT)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:RAYMOND
Last Name:AKERS
Suffix:
Gender:M
Credentials:PT
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 52194
Mailing Address - Street 2:DEPT CODE 961
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2194
Mailing Address - Country:US
Mailing Address - Phone:503-328-0222
Mailing Address - Fax:503-328-0223
Practice Address - Street 1:25500 SE STARK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3331
Practice Address - Country:US
Practice Address - Phone:503-328-0222
Practice Address - Fax:503-328-0223
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114556Medicare PIN
ORR114778Medicare PIN
ORR142701Medicare PIN
ORR114519Medicare PIN
ORR143478Medicare PIN
ORR134327Medicare PIN