Provider Demographics
NPI:1659340388
Name:PAINE, GINA MICHELE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:MICHELE
Last Name:PAINE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:MICHELE
Other - Last Name:BUNTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
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 1:1875 GOLF COURSE RD S
Practice Address - Street 2:TAI - VALLEY PHYSICAL THERAPY SOUTH
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9622
Practice Address - Country:US
Practice Address - Phone:503-585-4824
Practice Address - Fax:503-370-2545
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4186225100000X
FLPT20153225100000X
TX1149833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227892Medicaid
ORP00836821OtherRR
ORP00836821OtherRR MEDICARE
OR227892Medicaid