Basic Information
| Provider Information | |||||||||
| NPI: | 1689804957 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ELIAS | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1114 GEORGIANA ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983624212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604526216 | ||||||||
| FaxNumber: | 3604528765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 05/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60095069 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0252228 | 01 | WA | WASHINGTON L & I | OTHER | 1689804957 | 05 | WA | MEDICAID | P00802461 | 01 | WA | RR MEDICARE | OTHER |