Healthcare Provider Details

I. General information

NPI: 1417398561
Provider Name (Legal Business Name): GORDON OAKES PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 BOGACHIEL WAY
FORKS WA
98331-9120
US

IV. Provider business mailing address

530 BOGACHIEL WAY FORKS COMMUNITY HOSPITAL
FORTKS WA
98331
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-6271
  • Fax: 360-374-2520
Mailing address:
  • Phone: 360-374-6271
  • Fax: 360-374-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00001087
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: