Provider Demographics
NPI:1558763037
Name:LAVIGNE, BRENDA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:LAVIGNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:ANN
Other - Last Name:NUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD STE 430
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1624
Mailing Address - Fax:503-346-8285
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD STE 430
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-1627
Practice Address - Fax:503-346-8285
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1128895363A00000X
ORPA174984363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant