Provider Demographics
NPI:1235121542
Name:KOS, ALLISON ELIZABETH (PAC)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:ELIZABETH
Last Name:KOS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:ELIZABETH
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:#365
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-261-4430
Practice Address - Fax:503-261-4436
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00857363AS0400X
WAPA10004422363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR235820Medicaid
WA8434953Medicaid
OR116074Medicare ID - Type UnspecifiedPORTLAND
WAAB38160Medicare ID - Type UnspecifiedVANCOUVER
WA8434953Medicaid
ORP87459Medicare UPIN
OR118865Medicare ID - Type UnspecifiedSALEM
ORR157211Medicare PIN