Provider Demographics
NPI:1750654323
Name:WULF, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WULF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8614 E MILL PLAIN BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2092
Mailing Address - Country:US
Mailing Address - Phone:360-254-5267
Mailing Address - Fax:360-254-6089
Practice Address - Street 1:2565 NW LOVEJOY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2996
Practice Address - Country:US
Practice Address - Phone:503-279-9700
Practice Address - Fax:503-279-8114
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA164512207N00000X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant