Provider Demographics
NPI:1285844407
Name:TAKAGI, MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TAKAGI
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 1:422 N MAIN ST
Mailing Address - Street 2:PO BOX 597
Mailing Address - City:CONDON
Mailing Address - State:OR
Mailing Address - Zip Code:97823-7651
Mailing Address - Country:US
Mailing Address - Phone:541-384-2061
Mailing Address - Fax:
Practice Address - Street 1:422 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CONDON
Practice Address - State:OR
Practice Address - Zip Code:97823-7651
Practice Address - Country:US
Practice Address - Phone:541-384-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-295363A00000X
IDPA-791363A00000X
WYTL 568363A00000X
ORPA-165453363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant