Provider Demographics
NPI:1922089580
Name:ROSBOROUGH, TODD MICHAEL (PAC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:ROSBOROUGH
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 1:135 NE 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4167
Mailing Address - Country:US
Mailing Address - Phone:503-255-5388
Mailing Address - Fax:503-255-5085
Practice Address - Street 1:135 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4167
Practice Address - Country:US
Practice Address - Phone:503-255-5388
Practice Address - Fax:503-255-5085
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00576363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0131007OtherWA LABOR INDUSTRIES
S49213Medicare UPIN
105820Medicare ID - Type Unspecified