Healthcare Provider Details

I. General information

NPI: 1477744605
Provider Name (Legal Business Name): CHRISTINE MARY PANAGOS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE MARY PANAGOS DPT

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6217 NE 33RD AVE
PORTLAND OR
97211-7311
US

IV. Provider business mailing address

1920 S MANITOU AVE
BOISE ID
83706-4148
US

V. Phone/Fax

Practice location:
  • Phone: 503-784-5843
  • Fax:
Mailing address:
  • Phone: 503-784-5843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number5157
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: