MEDICARE: BRUCE FERNSTROM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00805	OR
2	363AS0400X	Surgical Physician Assistant	PA00805	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255329967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE FERNSTROM PA-C

Provider Business Mailing Address
First Line	:	541 NE 20TH AVE STE 225
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-2895
Country	:	US
Telephone Number	:	503-963-2801
Fax Number	:	503-963-2825

Provider Business Practice Location Address
First Line	:	501 N GRAHAM ST STE 420
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-2006
Country	:	US
Telephone Number	:	503-288-7303
Fax Number	:	503-288-3806

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	07/28/2025

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Directions to “ BRUCE FERNSTROM PA-C” Practice Location

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