Basic Information
| Provider Information | |||||||||
| NPI: | 1619915808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEA | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3417 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9719835260 | ||||||||
| FaxNumber: | 9719835326 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 NE 92ND AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986643225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605142142 | ||||||||
| FaxNumber: | 3605146820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10003486 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8357741 | 05 | WA | MEDICAID |