Provider Demographics
NPI:1841632981
Name:EGBERT, JOHN WESTON (DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WESTON
Last Name:EGBERT
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 1:1950 MATZEN RANCH CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-8595
Mailing Address - Country:US
Mailing Address - Phone:907-301-1856
Mailing Address - Fax:
Practice Address - Street 1:25 HILL DR
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1078
Practice Address - Country:US
Practice Address - Phone:907-301-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61568225100000X
WA6035487225100000X
CA300278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty