Provider Demographics
NPI:1558640508
Name:ROBINSON, WYATT JON
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:JON
Last Name:ROBINSON
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:SUITE 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 1:19017 120TH AVE NE BLDG 1
Practice Address - Street 2:SUITE 111
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-9510
Practice Address - Country:US
Practice Address - Phone:425-489-3420
Practice Address - Fax:425-489-3421
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60229384225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP1021705OtherRR MEDICARE
WA1558640508Medicaid
WA1558640508Medicaid