Provider Demographics
NPI:1669432662
Name:FORREST, MICHAEL J (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FORREST
Suffix:
Gender:M
Credentials:PA
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 3397
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 S WAHANNA RD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7735
Practice Address - Country:US
Practice Address - Phone:503-717-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA639363A00000X
ORPA01460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504788Medicaid
ORR150830Medicare PIN
NV100504788Medicaid
NVV101690Medicare PIN