Provider Demographics
NPI:1487771721
Name:MARICK, BRIDGET JEAN (PAC)
Entity type:Individual
Prefix:MS
First Name:BRIDGET
Middle Name:JEAN
Last Name:MARICK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:2850 SE POWELL VALLEY RD
Practice Address - Street 2:LEGACY GOHEALTH
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1494
Practice Address - Country:US
Practice Address - Phone:503-666-5050
Practice Address - Fax:503-666-1162
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001462363A00000X
ORPA179535363A00000X
WAPA60599711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79721206Medicaid
CO79721206Medicaid
COP52216Medicare UPIN