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NPI Code Detail

MEDICARE: NYRA G MABANTA PT, DPT

MEDICARE: NYRA G MABANTA PT, DPT
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
1225100000XPhysical Therapist65754OR

General Provider Information

NPI Number : 1578459046
Entity Type Code : Individual
Provider Name (Legal Business Name) : NYRA G MABANTA PT, DPT
Provider Business Mailing Address
First Line : 4560 SE INTERNATIONAL WAY STE 100
Second Line :
City : MILWAUKIE
State : OR
Zip : 97222-4628
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 515 TAGGART DR NW STE 150
Second Line :
City : SALEM
State : OR
Zip : 97304-4149
Country : US
Telephone Number : 503-363-6770
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/13/2025
Last Update Date : 06/13/2025

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