Basic Information
| Provider Information | |||||||||
| NPI: | 1134639719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRILL | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 108 NW SISEMORE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412132133 | ||||||||
| FaxNumber: | 5416408107 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 NW SISEMORE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412132133 | ||||||||
| FaxNumber: | 5416408107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2017 | ||||||||
| LastUpdateDate: | 06/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.