Provider Demographics
NPI:1043541832
Name:BALTAZAR, AMANDA D (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97331-8629
Mailing Address - Country:US
Mailing Address - Phone:541-768-7700
Mailing Address - Fax:541-768-9784
Practice Address - Street 1:845 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8629
Practice Address - Country:US
Practice Address - Phone:541-768-7700
Practice Address - Fax:541-768-9784
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60117609225100000X
OR60989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR60989OtherSTATE
WA0259144OtherLABOR & INDUSTRIES
WA0259144OtherLABOR & INDUSTRIES
WAG8905383Medicare PIN