| Doctor Name: | DR. PAUL E VANBREDAVRIESMAN |
| NPI Number: | 1043453582 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | MD11073 |
| Business Practice Address: | 18000 Se Stark Street Gresham, OR - 97233 |
| Business Phone Number: | 5032554243 |
| Business Fax Number: | 5032554243 |
| Mailing Address: | 16244 Ne San Rafael Dr, 18000 Se Stark Street PORTLAND |
| State: | OR |
| Postal Code: | 972305661 |
| Phone Number: | 5032554243 |
| Fax Number: | 5032554243 |
| NPI Enumeration Date: | 04/14/2009 |
| NPI Last Update Date: | 04/14/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 207QA0505X |
| License Number: | MD11073 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Family Medicine |
| Taxonomy Specialization: | Adult Medicine |
| Taxonomy Definition: | |