Provider Demographics
NPI:1801896535
Name:NYSTROM, LEESA D (PT)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:D
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7842
Mailing Address - Country:US
Mailing Address - Phone:541-773-7678
Mailing Address - Fax:541-773-5517
Practice Address - Street 1:924 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7842
Practice Address - Country:US
Practice Address - Phone:541-773-7678
Practice Address - Fax:541-773-5517
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR103679Medicare ID - Type Unspecified