Provider Demographics
NPI:1003873142
Name:BROWN, JEAN M (PA-C)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-388-1636
Mailing Address - Fax:
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-388-1636
Practice Address - Fax:541-388-1719
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI569-023363A00000X, 363AS0400X
ORPA01237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00834460OtherMEDICARE RAILROAD
WI2908OtherDEAN HEALTH INSURANCE
WI42923300Medicaid
WI970010935OtherRAILROAD MEDICARE
OR500605405Medicaid
OR500605405Medicaid
ORR138315Medicare PIN
ORR138315Medicare PIN