Provider Demographics
NPI:1770698102
Name:DEBROEKERT, DIRK G (PA-C)
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:G
Last Name:DEBROEKERT
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 1:28015 BRIGGS HILL RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-9747
Mailing Address - Country:US
Mailing Address - Phone:541-687-8298
Mailing Address - Fax:
Practice Address - Street 1:890 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3233
Practice Address - Country:US
Practice Address - Phone:541-688-0674
Practice Address - Fax:541-688-5378
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPP00278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR104149Medicare UPIN