Provider Demographics
NPI:1750050001
Name:ROTH, BRYAN GARY JAMES
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:GARY JAMES
Last Name:ROTH
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1775
Mailing Address - Fax:503-494-4749
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-1775
Practice Address - Fax:503-494-4749
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA207736363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant