Provider Demographics
NPI:1477851814
Name:WILKINS, KATRINA JOANN (DPT)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:JOANN
Last Name:WILKINS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:JOANN
Other - Last Name:STONEBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
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 1:8324 SE 17TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7307
Practice Address - Country:US
Practice Address - Phone:503-236-3837
Practice Address - Fax:503-206-8203
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37164225100000X, 2251X0800X
OR61113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW12026OtherGROUP PTAN
OR500734768Medicaid