Provider Demographics
NPI:1407083215
Name:WRIGHT, KELLY SHERIDAN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SHERIDAN
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-359-5564
Mailing Address - Fax:503-357-4371
Practice Address - Street 1:8332 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7102
Practice Address - Country:US
Practice Address - Phone:503-595-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD19283207R00000X
ORMD167227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002823501Medicare PIN
MEP01103102Medicare PIN
ME002823502Medicare PIN