Provider Demographics
NPI:1841672870
Name:KOSTENKO, KAREN L (PA-C)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:L
Last Name:KOSTENKO
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 1:1350 NE 122ND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2011
Mailing Address - Country:US
Mailing Address - Phone:503-408-7008
Mailing Address - Fax:
Practice Address - Street 1:1350 NE 122ND AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2011
Practice Address - Country:US
Practice Address - Phone:503-408-7008
Practice Address - Fax:503-666-6745
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53029363AM0700X
ORPA187236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical