Provider Demographics
NPI:1497143077
Name:BRASK, MICHAEL JOHNSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHNSON
Last Name:BRASK
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 1:2216 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-1204
Mailing Address - Country:US
Mailing Address - Phone:971-404-9118
Mailing Address - Fax:
Practice Address - Street 1:1001 N PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7485
Practice Address - Country:US
Practice Address - Phone:503-537-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA182326363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical