Provider Demographics
NPI:1366468688
Name:BREVARD, RYAN A (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:A
Last Name:BREVARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312 SW CAPITOL HWY # 502
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1938
Mailing Address - Country:US
Mailing Address - Phone:503-464-9034
Mailing Address - Fax:
Practice Address - Street 1:24800 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3378
Practice Address - Country:US
Practice Address - Phone:503-647-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24321207P00000X
WAMD44940207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227376Medicaid
OR120789Medicare ID - Type Unspecified
H94392Medicare UPIN