Provider Demographics
NPI:1578619680
Name:MISUDA, TAKASHI (PT)
Entity Type:Individual
Prefix:
First Name:TAKASHI
Middle Name:
Last Name:MISUDA
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 1:19255 POWDER HILL PL NE STE 200
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7455
Mailing Address - Country:US
Mailing Address - Phone:360-697-3003
Mailing Address - Fax:360-697-3026
Practice Address - Street 1:10452 SILVERDALE WAY NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9411
Practice Address - Country:US
Practice Address - Phone:360-307-7300
Practice Address - Fax:360-307-7304
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA505484Medicare ID - Type Unspecified