Provider Demographics
NPI:1629192497
Name:FORKAN, REBECCA A (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:FORKAN
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 1:8007 NE 147TH LN
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-4762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20109 AURORA AVE N STE 105
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3127
Practice Address - Country:US
Practice Address - Phone:206-801-7546
Practice Address - Fax:206-801-7547
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000098532251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ51624Medicare UPIN
WA8855845Medicare ID - Type UnspecifiedMEDICARE #