Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 61193 | OR |
N | 2251X0800X | Physical Therapist - Orthopedic | 61193 | OR |
NPI | 1245710847 |
---|---|
Provider Name | Trevor Thomas Pettigrew |
First Address | Portland, OR 97213-2236 |
Second Address | Portland, OR 97213-2236 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2018 |
Last Update Date | 14/08/2018 |