MEDICARE: DINA PEGANOFF PHYSICAL THERAPIST A

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	225200000X	Physical Therapy Assistant	8260	OR
2	225100000X	Physical Therapist	60695911	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01853434	OTHER	WA	RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1518058031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DINA PEGANOFF PHYSICAL THERAPIST A

Provider Business Mailing Address
First Line	:	16083 SW UPPER BOONES FERRY RD
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97224-7736
Country	:	US
Telephone Number	:	800-219-8835
Fax Number	:	503-639-9699

Provider Business Practice Location Address
First Line	:	3180 NE 3RD AVE
Second Line	:
City	:	CAMAS
State	:	WA
Zip	:	98607-2407
Country	:	US
Telephone Number	:	360-335-9033
Fax Number	:	360-335-9035

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/01/2017

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