Provider Demographics
NPI:1669612115
Name:PASTERNAK, BRYAN A (MPT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:A
Last Name:PASTERNAK
Suffix:
Gender:M
Credentials:MPT
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 22499
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2499
Mailing Address - Country:US
Mailing Address - Phone:503-496-0385
Mailing Address - Fax:866-633-1936
Practice Address - Street 1:14880 SW SUNRISE LN
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-1255
Practice Address - Country:US
Practice Address - Phone:503-496-0385
Practice Address - Fax:866-631-9368
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR37262251X0800X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR146485Medicare PIN