Provider Demographics
NPI:1275608838
Name:CRUISE, MICHAEL P (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:CRUISE
Suffix:
Gender:M
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 2847
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 SW COAST HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5017
Practice Address - Country:US
Practice Address - Phone:541-574-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3118207P00000X
ORPA01271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500606007Medicaid
OR500606007Medicaid
OR139521Medicare PIN