Provider Demographics
NPI:1316750201
Name:PHOMPHAKDY, TONY
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:PHOMPHAKDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20140 NE SANDY BLVD UNIT 112
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-9751
Mailing Address - Country:US
Mailing Address - Phone:503-984-1286
Mailing Address - Fax:
Practice Address - Street 1:2149 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1580
Practice Address - Country:US
Practice Address - Phone:503-281-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28326225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist