Provider Demographics
NPI:1689670226
Name:KELLY, LORI H (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:H
Last Name:KELLY
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:GH 219
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1484
Mailing Address - Fax:503-494-1409
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00942363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500602706Medicaid
WA8502619Medicaid
WA8502619Medicaid
ORQ15772Medicare UPIN