Provider Demographics
NPI:1336117035
Name:CVITASH, MICHAEL T (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:CVITASH
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 1:1508 DIVISION ST STE 105
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1584
Mailing Address - Country:US
Mailing Address - Phone:503-656-0836
Mailing Address - Fax:503-656-9464
Practice Address - Street 1:1508 DIVISION ST STE 105
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1584
Practice Address - Country:US
Practice Address - Phone:503-656-0836
Practice Address - Fax:503-656-9464
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA159365363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11832611OtherCAQH
NV100508235Medicaid
NVP00378675OtherRR MEDICARE
NVV102008Medicare PIN
NVP00378675OtherRR MEDICARE