Basic Information
| Provider Information | |||||||||
| NPI: | 1629317706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAZE | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | EMERSON | ||||||||
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| Credential: | P.T. | ||||||||
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| 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: | 2728 PHEASANT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417368870 | ||||||||
| FaxNumber: | 5417368860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2013 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 60057 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 500655109 | 05 | OR | MEDICAID | P01220789 | 01 | OR | RR MEDICARE | OTHER |