Provider Demographics
NPI:1619445715
Name:GRETZINGER, KELSEY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:GRETZINGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:LYNN
Other - Last Name:BENSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1155 NW EVERETT ST APT 319
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19255 SW 65TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9712
Practice Address - Country:US
Practice Address - Phone:503-828-1150
Practice Address - Fax:503-828-1160
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant