MEDICARE: LYNDSAY PROVENCIO PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	62930	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174001887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNDSAY PROVENCIO PT

Provider Business Mailing Address
First Line	:	16083 SW UPPER BOONES FERRY RD STE 300
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97224-7736
Country	:	US
Telephone Number	:	503-443-6156
Fax Number	:	503-639-9699

Provider Business Practice Location Address
First Line	:	4829 NE MLK JR BLVD STE 101
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3491
Country	:	US
Telephone Number	:	503-283-8133
Fax Number	:	503-287-0245

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2018
Last Update Date	:	09/20/2018

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Directions to “ LYNDSAY PROVENCIO PT” Practice Location

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