Provider Demographics
NPI:1205105202
Name:ANDERSON, DANIEL STEPHEN (DPT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:STEPHEN
Last Name:ANDERSON
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 1:12651 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1370
Mailing Address - Country:US
Mailing Address - Phone:425-891-3538
Mailing Address - Fax:
Practice Address - Street 1:12651 SE LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1370
Practice Address - Country:US
Practice Address - Phone:425-891-3538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65098225100000X
WAPT60257881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1205105202Medicaid
WAG8968737OtherMEDICARE
ORP01153274OtherRR MEDICARE
WAG8907999Medicare PIN