Provider Demographics
NPI:1669581542
Name:BAMBERGER, SUSAN KRETZMANN (PT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KRETZMANN
Last Name:BAMBERGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BARBARA
Other - Last Name:KRETZMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6255 SW CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-4200
Mailing Address - Country:US
Mailing Address - Phone:503-892-4564
Mailing Address - Fax:
Practice Address - Street 1:17120 PILKINGTON RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5353
Practice Address - Country:US
Practice Address - Phone:503-974-9078
Practice Address - Fax:503-974-9083
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3905208100000X
WA8064208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139607Medicare PIN