MEDICARE: TODD MICHAEL ROSBOROUGH PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA00576	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0131007	OTHER	WA	WA LABOR INDUSTRIES

General Provider Information

NPI Number	:	1922089580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TODD MICHAEL ROSBOROUGH PAC

Provider Business Mailing Address
First Line	:	135 NE 102ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-4167
Country	:	US
Telephone Number	:	503-255-5388
Fax Number	:	503-255-5085

Provider Business Practice Location Address
First Line	:	135 NE 102ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-4167
Country	:	US
Telephone Number	:	503-255-5388
Fax Number	:	503-255-5085

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	07/08/2007

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Directions to “ TODD MICHAEL ROSBOROUGH PAC” Practice Location

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