Healthcare Provider Details

I. General information

NPI: 1154919561
Provider Name (Legal Business Name): BRYHANNA CHRISTINECHARLES MCCULLY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD
GRESHAM OR
97080-1494
US

IV. Provider business mailing address

PO BOX 3777
PORTLAND OR
97208-3777
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5050
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax: 503-413-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA209821
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA209821
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008846
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: