Provider Demographics
NPI:1215672621
Name:JAILANI, RANDY LIM (PTA)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:LIM
Last Name:JAILANI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 SW NYBERG ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8437
Mailing Address - Country:US
Mailing Address - Phone:503-570-3365
Mailing Address - Fax:
Practice Address - Street 1:8100 SW NYBERG ST STE 200
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8437
Practice Address - Country:US
Practice Address - Phone:503-570-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCP004282A225200000X
TX2155382225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant