MEDICARE: BRADEN O'SHAUGHNESSY D.O.

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	207Q00000X	Family Medicine Physician	20A16736	CA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207Q00000X	Family Medicine Physician	OP61321863	WA

General Provider Information

NPI Number	:	1619402542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADEN O'SHAUGHNESSY D.O.

Provider Business Mailing Address
First Line	:	1115 SE 164TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-9324
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3125 OLD FAIRHAVEN PKWY STE 106
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-8266
Country	:	US
Telephone Number	:	360-788-8388
Fax Number	:	360-788-8389

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

Provider Enumeration Date	:	04/28/2017
Last Update Date	:	03/14/2023

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