Provider Demographics
NPI:1619241551
Name:QUARLES, BRETT ANTHONY (PAC)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:ANTHONY
Last Name:QUARLES
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5101
Mailing Address - Country:US
Mailing Address - Phone:503-226-6321
Mailing Address - Fax:503-227-3422
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5101
Practice Address - Country:US
Practice Address - Phone:503-226-6321
Practice Address - Fax:503-227-3422
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA164425363AS0400X
390200000X
WAPA60416858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006671545Medicaid
WA1619241551Medicaid
OR172717Medicare PIN
OR180345Medicare PIN