Provider Demographics
NPI:1730482324
Name:KAUSHIK, SUPRIYA S (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUPRIYA
Middle Name:S
Last Name:KAUSHIK
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 1:4400 NE HALSEY ST BLDG 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4400 NE HALSEY ST BLDG 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1545
Practice Address - Country:US
Practice Address - Phone:503-215-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA152640363A00000X
OR914238133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA152640OtherOREGON PA LICENSE