Provider Demographics
NPI:1194708057
Name:KEOWN, GARY DOUGLAS (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:DOUGLAS
Last Name:KEOWN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:D
Other - Last Name:KEOWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE 300
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 1:68643 HIGHWAY 20
Practice Address - Street 2:TAI CENTRAL OREGON SISTERS
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-1947
Practice Address - Country:US
Practice Address - Phone:541-849-3574
Practice Address - Fax:541-388-7785
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR170928Medicaid
ORR155107Medicare PIN
OR170928Medicaid