Healthcare Provider Details

I. General information

NPI: 1134597404
Provider Name (Legal Business Name): ALEXANDER WIRTA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19017 120TH AVE NE BLDG 1 SUITE 111
BOTHELL WA
98011-9510
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD SUITE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 425-489-3420
  • Fax: 425-489-3421
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 60555817
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier1134597404
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: