Provider Demographics
NPI:1053918367
Name:VONSEGGERN, JOANNA RENEE (PTA)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:RENEE
Last Name:VONSEGGERN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:RENEE
Other - Last Name:GROTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2625 KOOS BAY BLVD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4907
Practice Address - Country:US
Practice Address - Phone:541-267-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PTA-LIC-17197225200000X
OR9849225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant