Provider Demographics
NPI:1710057757
Name:LUCERO, WENDI A (PT)
Entity Type:Individual
Prefix:MS
First Name:WENDI
Middle Name:A
Last Name:LUCERO
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 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 1:17700 SE MILL PLAIN BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-7580
Practice Address - Country:US
Practice Address - Phone:360-514-9383
Practice Address - Fax:360-514-0193
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4686225100000X
WAPT00009378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1710057757Medicaid
OR500698426Medicaid
WA1710057757Medicaid
ORR186821Medicare PIN
ORR186818Medicare PIN
ORR186819Medicare PIN
ORR186816Medicare PIN
ORR186817Medicare PIN
WAG8951524Medicare PIN