Provider Demographics
NPI:1952597809
Name:STIBAL, RONALD (PT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:STIBAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5736 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3750
Mailing Address - Country:US
Mailing Address - Phone:971-808-5045
Mailing Address - Fax:503-236-3239
Practice Address - Street 1:13306 NW CORNELL RD STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5806
Practice Address - Country:US
Practice Address - Phone:971-245-6217
Practice Address - Fax:503-521-7950
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6831225100000X
FLPT 17941225100000X
OR06831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500649186Medicaid
ORR167186Medicare PIN