Provider Demographics
NPI:1699942011
Name:FALLER, BRENDA M (RPA/RA, RT(R))
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:FALLER
Suffix:
Gender:F
Credentials:RPA/RA, RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 NE 47TH AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2238
Mailing Address - Country:US
Mailing Address - Phone:971-344-0499
Mailing Address - Fax:
Practice Address - Street 1:545 NE 47TH AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2238
Practice Address - Country:US
Practice Address - Phone:971-344-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106318247100000X
06 WA 1235243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist