Provider Demographics
NPI:1689185506
Name:GONZALEZ, EDGAR (LMT)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5989 SE HARMONY RD APT 12
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2111
Mailing Address - Country:US
Mailing Address - Phone:503-840-7462
Mailing Address - Fax:
Practice Address - Street 1:17777 LOWER BOONES FERRY RD STE A
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5398
Practice Address - Country:US
Practice Address - Phone:503-699-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20741225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist