Provider Demographics
NPI:1427729953
Name:MEJORADO, BROOKE TAYLOR (PA-C)
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:TAYLOR
Last Name:MEJORADO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7325 SE 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-8301
Mailing Address - Country:US
Mailing Address - Phone:209-275-5951
Mailing Address - Fax:
Practice Address - Street 1:801 MISSION ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6217
Practice Address - Country:US
Practice Address - Phone:503-588-3945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA207447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant