Provider Demographics
NPI:1528798063
Name:OBRIEN, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:OBRIEN
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 1:2945 NE 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3460
Mailing Address - Country:US
Mailing Address - Phone:503-505-4107
Mailing Address - Fax:
Practice Address - Street 1:1475 SE 100TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2537
Practice Address - Country:US
Practice Address - Phone:503-262-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant