Provider Demographics
NPI:1760560734
Name:BONEY, ROBERT M (MPT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:BONEY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:M
Other - Last Name:BONEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:6012 NE 175TH CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6012 NE 175TH CIR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1775
Practice Address - Country:US
Practice Address - Phone:360-560-9219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00006372225100000X
OR2429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0130397OtherL I
WA7107972Medicaid
WAAB23014Medicare ID - Type Unspecified