Provider Demographics
NPI:1174205603
Name:ITO, DYLAN JITSUO (DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:JITSUO
Last Name:ITO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14766 SW SCHOLLS FERRY RD APT 1236
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-8984
Mailing Address - Country:US
Mailing Address - Phone:808-936-2414
Mailing Address - Fax:
Practice Address - Street 1:14766 SW SCHOLLS FERRY RD APT 1236
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-8984
Practice Address - Country:US
Practice Address - Phone:808-936-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR650502251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic