Provider Demographics
NPI:1083009872
Name:MCNAUGHTON, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MCNAUGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 EXCHANGE ST STE 304
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3307
Mailing Address - Country:US
Mailing Address - Phone:503-325-8315
Mailing Address - Fax:
Practice Address - Street 1:2158 EXCHANGE ST
Practice Address - Street 2:SUITE 304
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3316
Practice Address - Country:US
Practice Address - Phone:503-325-8315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201501751RN363L00000X
OR201501752NP-PP363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083009872Medicaid