Provider Demographics
NPI:1164049995
Name:FARE, BRENT DAVID (CCP)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DAVID
Last Name:FARE
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7241 SW 13TH DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2073
Mailing Address - Country:US
Mailing Address - Phone:503-319-9457
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080013242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionistGroup - Single Specialty