Provider Demographics
NPI:1831578400
Name:PUST, KEVIN M (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:PUST
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 NE VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3827
Mailing Address - Country:US
Mailing Address - Phone:503-489-6250
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:1630 BEAVERCREEK RD
Practice Address - Street 2:SUITE A
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4156
Practice Address - Country:US
Practice Address - Phone:503-489-6250
Practice Address - Fax:503-489-1650
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist