Provider Demographics
NPI:1770797078
Name:PUTH, NANCY (MPT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:PUTH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 NE 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6807
Mailing Address - Country:US
Mailing Address - Phone:503-215-9103
Mailing Address - Fax:
Practice Address - Street 1:270 NW BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3836
Practice Address - Country:US
Practice Address - Phone:503-215-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist