Provider Demographics
NPI:1639155237
Name:VANDE POL, PHILIP (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:VANDE POL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
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:2005-12-16
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4927225100000X
WAPT00010802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1639155237Medicaid
WA8501348Medicaid
OR278011Medicaid
OR131649Medicare PIN