=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205164480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JON O'ROURKE PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2009
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 S 320TH ST
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-946-2960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32522 1ST PL S
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-5711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-517-9622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | P1 60041032
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 0738
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------