Provider Demographics
NPI:1689804957
Name:ELIAS, AUDREY R (PT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:R
Last Name:ELIAS
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 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 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 1:1114 GEORGIANA ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4212
Practice Address - Country:US
Practice Address - Phone:360-452-6216
Practice Address - Fax:360-452-8765
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60095069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0252228OtherWASHINGTON L & I
WA1689804957Medicaid
WAP00802461OtherRR MEDICARE
WAG8883736Medicare PIN