Provider Demographics
NPI:1306293238
Name:WALL, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 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 1:283 NW MILLER AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7260
Practice Address - Country:US
Practice Address - Phone:503-666-7644
Practice Address - Fax:503-674-9980
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR194481OtherMEDICARE
ORR194486OtherMEDICARE
OR500723506Medicaid
ORR194485OtherMEDICARE
ORR194482OtherMEDICARE
ORR194484OtherMEDICARE
ORR194483OtherMEDICARE