Healthcare Provider Details

I. General information

NPI: 1508186669
Provider Name (Legal Business Name): JOHN RICHARD NIELSEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 OLIVE WAY SUITE 1011
SEATTLE WA
98101-1720
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: 206-623-4570
  • Fax: 206-623-4574
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT06294
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60628838
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: