Provider Demographics
NPI:1013096684
Name:MCCUSKER, MICHAEL J (P A-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MCCUSKER
Suffix:
Gender:M
Credentials:P A-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 NW SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2111
Mailing Address - Country:US
Mailing Address - Phone:541-758-0766
Mailing Address - Fax:541-753-2737
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6611
Practice Address - Fax:541-766-6186
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01335363AM0700X
PAMA052623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500634427Medicaid
ORPA01335OtherOREGON MEDICAL BOARD
ORPA01335OtherOREGON MEDICAL BOARD