Provider Demographics
NPI:1528553682
Name:MOSTKOFF, JERRAH MARIA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JERRAH
Middle Name:MARIA
Last Name:MOSTKOFF
Suffix:
Gender:F
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 1:8338 SE MILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1435
Mailing Address - Country:US
Mailing Address - Phone:724-496-6382
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST STE 304
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5100
Practice Address - Country:US
Practice Address - Phone:503-413-4992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114907363A00000X
PAMA059838363AM0700X
ORPA215067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113811500Medicaid
FLO0REOOtherBCBS