Healthcare Provider Details

I. General information

NPI: 1174387609
Provider Name (Legal Business Name): MONIKA RENEE DESHAZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 NE 201ST AVE
FAIRVIEW OR
97024-2499
US

IV. Provider business mailing address

21021 SE BURNSIDE CT
GRESHAM OR
97030-3643
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-7200
  • Fax:
Mailing address:
  • Phone: 503-381-9981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8850
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: