Healthcare Provider Details

I. General information

NPI: 1497143077
Provider Name (Legal Business Name): MICHAEL JOHNSON BRASK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N PROVIDENCE DR
NEWBERG OR
97132-7485
US

IV. Provider business mailing address

2216 ARBOR DR
WEST LINN OR
97068-1204
US

V. Phone/Fax

Practice location:
  • Phone: 503-537-1785
  • Fax:
Mailing address:
  • Phone: 971-404-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA182326
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: