Provider Demographics
NPI:1083166037
Name:BROZOVICH, COURTNEY E (PAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:E
Last Name:BROZOVICH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:E
Other - Last Name:DALKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1600 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4257
Mailing Address - Country:US
Mailing Address - Phone:503-540-6300
Mailing Address - Fax:503-540-6404
Practice Address - Street 1:665 WINTER ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3934
Practice Address - Country:US
Practice Address - Phone:503-541-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA180126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA180126OtherPA LICENSE
OR500718145Medicaid
ORPA180126OtherPA LICENSE