Provider Demographics
NPI:1295818383
Name:VAN ATTA, JENNIFER K (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:VAN ATTA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15755 SW SEQUOIA PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7166
Mailing Address - Country:US
Mailing Address - Phone:503-639-6002
Mailing Address - Fax:503-639-1403
Practice Address - Street 1:15755 SW SEQUOIA PKWY STE 200
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7166
Practice Address - Country:US
Practice Address - Phone:503-639-6002
Practice Address - Fax:503-639-1403
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001920Medicaid
OR500604336Medicaid
OR93-1280904OtherTAX ID
ORR106488Medicare PIN
OR001920Medicaid