Provider Demographics
NPI:1922305424
Name:O'FALLON, ERIC C (DPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:O'FALLON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 132ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-7203
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:
Practice Address - Street 1:1519 132ND ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-7203
Practice Address - Country:US
Practice Address - Phone:425-337-9556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60205220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0275587OtherL&I
WA0275589OtherL&I
WA1922305424OtherDSHS
WA0275550OtherL&I
WA0275594OtherL&I
WAG8899247Medicare PIN
WA0275587OtherL&I
WAG8899248Medicare PIN
WA1922305424OtherDSHS