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General NPI Number Information
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NPI Number | 1487173340
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Entity Type | Individual
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Provider Name | LANA KRISTINE WIRGES LMT
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Gender | Female
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Dates
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Enumeration Date | 09/12/2017
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Last Update Date | 09/12/2017
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Provider Practice Location Address
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Address Line | 210 NW 17TH AVE
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City | PORTLAND
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State | OR
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Zip | 97209-2151
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Country | US
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Telephone | 971-407-3066
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Fax |
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Provider Business Mailing Address
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Address Line | 5704 NE MASON ST
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City | PORTLAND
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State | OR
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Zip | 97218-2210
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Country | US
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Telephone | 503-688-8001
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 15383
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License Number State | OR
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