Provider Demographics
NPI:1659578557
Name:DAVIS, MIKE STUART (PTA)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:STUART
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 RYAN CT
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4034
Mailing Address - Country:US
Mailing Address - Phone:503-655-5698
Mailing Address - Fax:
Practice Address - Street 1:5415 SW WESTGATE DR STE L3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2409
Practice Address - Country:US
Practice Address - Phone:503-297-3003
Practice Address - Fax:503-297-9414
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1353225200000X
OR8463225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant