Basic Information
| Provider Information | |||||||||
| NPI: | 1114362944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYSON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARSON | ||||||||
| OtherFirstName: | VICTORIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 20055 SW PACIFIC HWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SHERWOOD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971409294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036251691 | ||||||||
| FaxNumber: | 5039251460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2013 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 60041 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01491759 | 01 | OR | RR MEDICARE PTAN | OTHER | 500657071 | 05 | OR | MEDICAID |