Provider Demographics
NPI:1013581222
Name:ST. AMAND, KELSEY JORDAN (PA-C, MPH)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JORDAN
Last Name:ST. AMAND
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:JORDAN
Other - Last Name:DE LEMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD # L353
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:661-678-3778
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD # L353
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-4190
Practice Address - Fax:503-494-7829
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA211583363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500809282Medicaid