Provider Demographics
NPI:1770523805
Name:GARRISON, RODNEY R (PA-C)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:R
Last Name:GARRISON
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 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:STE. 606
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3093
Mailing Address - Country:US
Mailing Address - Phone:502-229-7554
Mailing Address - Fax:503-274-5400
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:STE. 406
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-435-1200
Practice Address - Fax:503-434-9572
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000432363A00000X
ORPA01228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500605531Medicaid
OR138241Medicare PIN
OR500605531Medicaid