Healthcare Provider Details

I. General information

NPI: 1194865733
Provider Name (Legal Business Name): LISA M KENSIL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-5179
  • Fax: 503-905-0495
Mailing address:
  • Phone: 971-206-5179
  • Fax: 503-905-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01171
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: