Provider Demographics
NPI:1003340613
Name:COLMENERO, ALEJANDRO ELLIOTT I (MSPA, PA-C)
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:ELLIOTT
Last Name:COLMENERO
Suffix:I
Gender:M
Credentials:MSPA, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 MARCOLA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-2594
Mailing Address - Country:US
Mailing Address - Phone:541-747-4300
Mailing Address - Fax:541-747-0655
Practice Address - Street 1:21 HAYDEN BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1305
Practice Address - Country:US
Practice Address - Phone:541-747-4300
Practice Address - Fax:541-747-0655
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363A00000X
ORPA183504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500726848Medicaid