Provider Demographics
NPI:1184789703
Name:VAN PEVENAGE, MICHAEL G (RPT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:VAN PEVENAGE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-0752
Mailing Address - Country:US
Mailing Address - Phone:509-725-7325
Mailing Address - Fax:509-725-5325
Practice Address - Street 1:506 MORGAN STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122
Practice Address - Country:US
Practice Address - Phone:509-725-7325
Practice Address - Fax:509-725-5325
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125768Medicaid
WADF0622OtherPALMETTO
WA0205378OtherLABOR AND INDUSTRIES
WAG8858341Medicare ID - Type Unspecified