Provider Demographics
NPI:1083635916
Name:RECKARD, KENNETH LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:RECKARD
Suffix:
Gender:M
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 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2801
Practice Address - Street 1:19250 SW 90TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7585
Practice Address - Country:US
Practice Address - Phone:503-692-3750
Practice Address - Fax:503-691-2324
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01082363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604351Medicaid
WA1083635916Medicaid
OR500604351Medicaid
OR171047Medicare PIN
OR171048Medicare PIN
ORP01340195Medicare PIN
OROTH000Medicare UPIN
OR139504Medicare PIN