Provider Demographics
NPI:1619915808
Name:BEA, BRIAN R (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BEA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3417
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3417
Mailing Address - Country:US
Mailing Address - Phone:971-983-5260
Mailing Address - Fax:971-983-5326
Practice Address - Street 1:600 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3225
Practice Address - Country:US
Practice Address - Phone:360-514-2142
Practice Address - Fax:360-514-6820
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8357741Medicaid
WAG8855551Medicare PIN
WAS08490Medicare UPIN