Provider Demographics
NPI:1538337977
Name:ANTRIM, CHRISTA K
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:K
Last Name:ANTRIM
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 1:1600 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4257
Mailing Address - Country:US
Mailing Address - Phone:503-540-6472
Mailing Address - Fax:503-540-6480
Practice Address - Street 1:1600 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4257
Practice Address - Country:US
Practice Address - Phone:503-540-6472
Practice Address - Fax:503-540-6480
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR49942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR272630Medicaid
OR141128Medicare PIN