Provider Demographics
NPI:1386964401
Name:COLLISON, MICHAEL CRAIG (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:COLLISON
Suffix:
Gender:M
Credentials:DPT
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 1:19255 SW 65TH AVE
Practice Address - Street 2:STE. 120
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-692-4934
Practice Address - Fax:503-691-9655
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01152128OtherRR MEDICARE
OR500637032Medicaid
ORP01152128OtherRR MEDICARE
ORR160620Medicare PIN