Provider Demographics
NPI:1821400169
Name:FIELDSTED, RHETT
Entity Type:Individual
Prefix:
First Name:RHETT
Middle Name:
Last Name:FIELDSTED
Suffix:
Gender:M
Credentials:
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 1:702 SW RAMSEY AVE
Practice Address - Street 2:STE. 220
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5858
Practice Address - Country:US
Practice Address - Phone:541-479-0765
Practice Address - Fax:541-736-8860
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0327609OtherWA L&I
OR500672686Medicaid
ORP01396207OtherRR MEDICARE PTAN
ORR177296Medicare PIN