Provider Demographics
NPI:1558863019
Name:DAVIS, BRIAN ROBERT (MS, ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6636 SW VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3506
Mailing Address - Country:US
Mailing Address - Phone:206-919-6867
Mailing Address - Fax:
Practice Address - Street 1:930 SW HALL ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-9720
Practice Address - Country:US
Practice Address - Phone:503-725-4073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-101545542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer