Provider Demographics
NPI:1508057480
Name:LEDESMA, EVE WINONA (PT)
Entity Type:Individual
Prefix:MRS
First Name:EVE
Middle Name:WINONA
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9219
Mailing Address - Country:US
Mailing Address - Phone:541-929-2156
Mailing Address - Fax:
Practice Address - Street 1:2750 NW HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5208
Practice Address - Country:US
Practice Address - Phone:541-768-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274085OtherOREGON STATE DMAP