Healthcare Provider Details

I. General information

NPI: 1285884114
Provider Name (Legal Business Name): HEIDI JO KELBAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR STE 145
GRESHAM OR
97030-3795
US

IV. Provider business mailing address

7650 SW BEVELAND RD STE 200
PORTLAND OR
97223-8692
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-2650
  • Fax: 503-489-2659
Mailing address:
  • Phone: 503-601-3615
  • Fax: 503-840-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA164192
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: