Healthcare Provider Details

I. General information

NPI: 1851812044
Provider Name (Legal Business Name): BRANDON ROSES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 W MAIN ST
MOLALLA OR
97038-9352
US

IV. Provider business mailing address

PO BOX 3417
PORTLAND OR
97208-3417
US

V. Phone/Fax

Practice location:
  • Phone: 503-874-5653
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax: 503-413-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA182825
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: