Provider Demographics
NPI:1326850272
Name:BOEN, GAVIN
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:BOEN
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 1:473 MANBRIN DR N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-5801
Mailing Address - Country:US
Mailing Address - Phone:541-419-4802
Mailing Address - Fax:
Practice Address - Street 1:755 MISSION ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6211
Practice Address - Country:US
Practice Address - Phone:503-814-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist