Healthcare Provider Details

I. General information

NPI: 1275156721
Provider Name (Legal Business Name): ANNALEE DEWEY GONZALEZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 NE 4TH AVE
HILLSBORO OR
97124-1859
US

IV. Provider business mailing address

3215 NE 4TH AVE
HILLSBORO OR
97124-1859
US

V. Phone/Fax

Practice location:
  • Phone: 503-927-7778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2152677
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6492
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9854
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: