Healthcare Provider Details

I. General information

NPI: 1528151206
Provider Name (Legal Business Name): PETER P MUSACCHIO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 SE SUNNYSIDE ROAD
CLACKAMAS OR
97015-9750
US

IV. Provider business mailing address

9800 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9750
US

V. Phone/Fax

Practice location:
  • Phone: 503-653-6440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00641
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10004785
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: