Provider Demographics
NPI:1023083979
Name:HERIGSTAD, BYRON J (PT)
Entity type:Individual
Prefix:MR
First Name:BYRON
Middle Name:J
Last Name:HERIGSTAD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20400 NE NIEDERBERGER RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9005
Mailing Address - Country:US
Mailing Address - Phone:503-538-5841
Mailing Address - Fax:
Practice Address - Street 1:120-C N EVEREST RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132
Practice Address - Country:US
Practice Address - Phone:503-538-8952
Practice Address - Fax:503-537-2027
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR318492OtherPROVIDENCE HEALTH PLAN
OR071014Medicaid
OR5732048OtherAETNA
ORK7283 01OtherPACIFIC SOURCE
ORK7283 01OtherPACIFIC SOURCE