Provider Demographics
NPI:1174387609
Name:DESHAZER, MONIKA RENEE
Entity type:Individual
Prefix:
First Name:MONIKA
Middle Name:RENEE
Last Name:DESHAZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21021 SE BURNSIDE CT
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3643
Mailing Address - Country:US
Mailing Address - Phone:503-381-9981
Mailing Address - Fax:
Practice Address - Street 1:1204 NE 201ST AVE
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-2499
Practice Address - Country:US
Practice Address - Phone:503-661-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8850225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant