Healthcare Provider Details

I. General information

NPI: 1013096684
Provider Name (Legal Business Name): MICHAEL J MCCUSKER P. A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NW 27TH ST
CORVALLIS OR
97330-5223
US

IV. Provider business mailing address

981 NW SPRUCE AVE
CORVALLIS OR
97330-2111
US

V. Phone/Fax

Practice location:
  • Phone: 541-766-6611
  • Fax: 541-766-6186
Mailing address:
  • Phone: 541-758-0766
  • Fax: 541-753-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01335
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA052623
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: