Provider Demographics
NPI:1962141085
Name:MODINA, JOHN MATTHEW TAN (PT)
Entity type:Individual
Prefix:
First Name:JOHN MATTHEW
Middle Name:TAN
Last Name:MODINA
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 1:10804 NE 44TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-6610
Mailing Address - Country:US
Mailing Address - Phone:360-949-8491
Mailing Address - Fax:
Practice Address - Street 1:332 NE SAN RAFAEL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3948
Practice Address - Country:US
Practice Address - Phone:503-288-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR644742251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic