Provider Demographics
NPI:1588755490
Name:WEATHERFORD, JUSTIN THOMAS (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:WEATHERFORD
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9148 SE HIDEAWAY CT
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-6324
Mailing Address - Country:US
Mailing Address - Phone:503-666-4505
Mailing Address - Fax:
Practice Address - Street 1:9148 SE HIDEAWAY CT
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:OR
Practice Address - Zip Code:97089-6324
Practice Address - Country:US
Practice Address - Phone:503-666-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4982225100000X
WAPT00009852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273806OtherOMAP #