Provider Demographics
NPI:1649031642
Name:BLAKLEY, LISA (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLAKLEY
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST STE 422
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5102
Practice Address - Country:US
Practice Address - Phone:503-227-7117
Practice Address - Fax:503-227-7120
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA220196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant