Individual
C THOMAS PROVENZANO
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
MPT
Contact information
Practice address
9260 SE STARK ST, SUITE B, PORTLAND, OR 97216-1675
(503) 255-1500
(503) 255-1560
Mailing address
6809 NE HANCOCK ST, PORTLAND, OR 97213-5343
(503) 280-7346
(503) 255-1560
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2227
OR
Other
Enumeration date
11/10/2005
Last updated
07/08/2007
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