Provider Demographics
NPI:1245256981
Name:MEYER, JESS M (PAC)
Entity type:Individual
Prefix:MR
First Name:JESS
Middle Name:M
Last Name:MEYER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24076 SE STARK ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3373
Mailing Address - Country:US
Mailing Address - Phone:503-661-5388
Mailing Address - Fax:503-666-9393
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:SUITE 110
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-661-5388
Practice Address - Fax:503-666-9393
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA151986363AS0400X
WAPA10004678363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8805791Medicare ID - Type Unspecified
WAQ20612Medicare UPIN