MEDICARE: GINA MARIE DUGAN COTA

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	224Z00000X	Occupational Therapy Assistant	989905	OR

General Provider Information

NPI Number	:	1841612140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA MARIE DUGAN COTA

Provider Business Mailing Address
First Line	:	7214 SE 21ST AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-5848
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4560 SE INTERNATIONAL WAY
Second Line	:	SUITE 101
City	:	PORTLAND
State	:	OR
Zip	:	97222-4628
Country	:	US
Telephone Number	:	971-206-5202
Fax Number	:	971-206-5203

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

Provider Enumeration Date	:	01/06/2014
Last Update Date	:	01/06/2014

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