Provider Demographics
NPI:1821767146
Name:PACKHAM, ALEXANDER DOUGLAS (LMT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DOUGLAS
Last Name:PACKHAM
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 1:21301 MAIN ST NE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OR
Mailing Address - Zip Code:97002-9243
Mailing Address - Country:US
Mailing Address - Phone:503-449-4334
Mailing Address - Fax:
Practice Address - Street 1:8695 SW JACK BURNS BLVD STE E
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-5797
Practice Address - Country:US
Practice Address - Phone:503-427-4698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20647225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty