Provider Demographics
NPI:1154963692
Name:BROCKWAY, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17455 SW 108TH PL
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8427
Mailing Address - Country:US
Mailing Address - Phone:503-298-1935
Mailing Address - Fax:
Practice Address - Street 1:17455 SW 108TH PL
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8427
Practice Address - Country:US
Practice Address - Phone:503-298-1935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDZ1386Medicaid