Provider Demographics
NPI:1659579902
Name:FAST, MARIE JOSETTE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:JOSETTE
Last Name:FAST
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 1:14130 SW BARROWS RD APT 1
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5748
Mailing Address - Country:US
Mailing Address - Phone:503-579-0168
Mailing Address - Fax:
Practice Address - Street 1:5701 SW MULTNOMAH BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3195
Practice Address - Country:US
Practice Address - Phone:503-977-1796
Practice Address - Fax:503-977-1796
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3327225100000X
CA9929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist