Provider Demographics
NPI:1780780619
Name:BRISCO, REBECCA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:BRISCO
Suffix:
Gender:F
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 1:940 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-1699
Mailing Address - Country:US
Mailing Address - Phone:541-396-3111
Mailing Address - Fax:541-824-1702
Practice Address - Street 1:940 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1699
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:541-396-8135
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA195440363AS0400X
WAPA60739138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2078139Medicaid
8B5819Medicare ID - Type Unspecified
TXP55910Medicare UPIN