Provider Demographics
NPI:1487639977
Name:HIRTLE, DAN WAKEFIELD (PT)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:WAKEFIELD
Last Name:HIRTLE
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 1:211 DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-9908
Mailing Address - Country:US
Mailing Address - Phone:541-315-2851
Mailing Address - Fax:541-315-2853
Practice Address - Street 1:211 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9908
Practice Address - Country:US
Practice Address - Phone:541-315-2851
Practice Address - Fax:541-315-2853
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295705Medicaid
OR650012922OtherRR MEDICARE
OR104287Medicare PIN