Provider Demographics
NPI:1033437298
Name:BANE, JENNIFER KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:BANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE STE 1301
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2714
Mailing Address - Country:US
Mailing Address - Phone:503-228-0155
Mailing Address - Fax:503-226-8342
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 1301
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-228-0155
Practice Address - Fax:503-226-8342
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA173635207K00000X
WAPA10004564363AM0700X
OR173635363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2010430Medicaid
P25953Medicare UPIN
WAG8892291Medicare PIN