Provider Demographics
NPI:1962418905
Name:GREEN, DAGAN ADAIR (MS PT)
Entity type:Individual
Prefix:
First Name:DAGAN
Middle Name:ADAIR
Last Name:GREEN
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:702 SW RAMSEY AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5858
Practice Address - Country:US
Practice Address - Phone:541-479-0765
Practice Address - Fax:541-479-3461
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-02-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WYPT959225100000X
OR6358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116812600Medicaid
OR500626304Medicaid
ORP00877705OtherRR MEDICARE
OR500626304Medicaid
WYW309068Medicare PIN