Provider Demographics
NPI:1265767834
Name:MONG, NICHOLAS ROBERT (PT, DPT, ATC)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:MONG
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 SW 158TH AVE # 160
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4952
Mailing Address - Country:US
Mailing Address - Phone:503-597-0035
Mailing Address - Fax:503-296-2985
Practice Address - Street 1:735 SW 158TH AVE # 160
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4952
Practice Address - Country:US
Practice Address - Phone:503-597-0035
Practice Address - Fax:503-296-2985
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05888225100000X
PART0041812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer