Provider Demographics
NPI:1528361680
Name:LUSCOMBE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LUSCOMBE
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 300
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 1:58147 COLUMBIA RIVER HWY
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6226
Practice Address - Country:US
Practice Address - Phone:503-397-1914
Practice Address - Fax:503-366-0422
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 6368225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500629366Medicaid
OR500629366Medicaid