Provider Demographics
NPI:1720362882
Name:GRAYBOSCH, KELLIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:GRAYBOSCH
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:STE 495
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500640073Medicaid
ORP01046628OtherRR MEDICARE (PH&S)
ORP01046628OtherRR MEDICARE (PH&S)
ORR162724Medicare PIN