Healthcare Provider Details

I. General information

NPI: 1821502576
Provider Name (Legal Business Name): KEVIN SKOLNIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7551
  • Fax: 503-494-4997
Mailing address:
  • Phone: 503-494-7551
  • Fax: 503-494-4997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA185439
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA185439
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: