Provider Demographics
NPI:1518058031
Name:PEGANOFF, DINA (PHYSICAL THERAPIST A)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:PEGANOFF
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:
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 1:3180 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2407
Practice Address - Country:US
Practice Address - Phone:360-335-9033
Practice Address - Fax:360-335-9035
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8260225200000X
WA60695911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01853434OtherRR MEDICARE
WA1518058031Medicaid
WAG8960607Medicare PIN