Provider Demographics
NPI:1407918501
Name:SANDQUIST, KENT MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:MICHAEL
Last Name:SANDQUIST
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4547
Mailing Address - Country:US
Mailing Address - Phone:541-889-8410
Mailing Address - Fax:541-889-8093
Practice Address - Street 1:335 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4547
Practice Address - Country:US
Practice Address - Phone:541-889-8410
Practice Address - Fax:541-889-8093
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01105363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500636562Medicaid
ORPA01105OtherLICENSE
OR093WCRBVAMedicare PIN