Provider Demographics
NPI:1174883102
Name:PESTKA, BRANDY SHAY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:SHAY
Last Name:PESTKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 N CHANNEL AVE
Mailing Address - Street 2:BLD. 72
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7655
Mailing Address - Country:US
Mailing Address - Phone:503-228-0295
Mailing Address - Fax:
Practice Address - Street 1:5555 N CHANNEL AVE
Practice Address - Street 2:BLD. 72
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-7655
Practice Address - Country:US
Practice Address - Phone:503-228-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant