Provider Demographics
NPI:1336987189
Name:ORTIZ, COLIN IRVIN HOLGANZA (PT)
Entity type:Individual
Prefix:
First Name:COLIN IRVIN
Middle Name:HOLGANZA
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0552
Mailing Address - Country:US
Mailing Address - Phone:253-386-0758
Mailing Address - Fax:
Practice Address - Street 1:316 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9140
Practice Address - Country:US
Practice Address - Phone:360-642-6328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61337277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist