Provider Demographics
NPI:1366402158
Name:IVERSON VON WULLERSTORFF, LAURA A (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:IVERSON VON WULLERSTORFF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:IVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1188 106TH AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8614
Mailing Address - Country:US
Mailing Address - Phone:425-454-4864
Mailing Address - Fax:425-646-3901
Practice Address - Street 1:11800 NE 128TH STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-820-0869
Practice Address - Fax:425-820-1745
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP34347Medicare UPIN
WAG8803957Medicare PIN
WAG8907010Medicare PIN