Healthcare Provider Details

I. General information

NPI: 1619127511
Provider Name (Legal Business Name): LISA GWEN YIRKA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 TUCKER RD
TOLEDO WA
98591-8685
US

IV. Provider business mailing address

800 TUCKER RD
TOLEDO WA
98591-8685
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-0319
  • Fax:
Mailing address:
  • Phone: 360-623-0319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP160031772
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: