Provider Demographics
NPI:1750087607
Name:CERCONE, KENDALL (PTA)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:CERCONE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1411 NW QUIMBY ST APT 312
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-4090
Mailing Address - Country:US
Mailing Address - Phone:330-671-5800
Mailing Address - Fax:
Practice Address - Street 1:6003 SE 136TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-4567
Practice Address - Country:US
Practice Address - Phone:971-978-1268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant