Provider Demographics
NPI:1265416291
Name:BOOTH, MATTHEW RYAN (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:415 E PARKCENTER BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6504
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:208-433-9241
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3968225100000X
IDRPT1329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805292000Medicaid
ID805292002Medicaid
ID1265416291-000Medicaid
IDP00802453OtherRR MEDICARE
ID0330326OtherWA L&I
ID126546291-002Medicaid
ID805292002Medicaid