Provider Demographics
NPI:1851783252
Name:MIKALSON, STEVEN WAYNE (LMT)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:WAYNE
Last Name:MIKALSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:STEVEN
Other - Middle Name:W
Other - Last Name:MIKALSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:4004 SW KELLY AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4004 SW KELLY AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4389
Practice Address - Country:US
Practice Address - Phone:503-241-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR42982081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine