Basic Information
| Provider Information | |||||||||
| NPI: | 1013096684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCUSKER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P. A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 981 NW SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973302111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417580766 | ||||||||
| FaxNumber: | 5417532737 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NW 27TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973305223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666611 | ||||||||
| FaxNumber: | 5417666186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA01335 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | MA052623 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500634427 | 05 | OR | MEDICAID | MM1460461 | 01 | DEA | OTHER | PA01335 | 01 | OR | OREGON MEDICAL BOARD | OTHER |