Healthcare Provider Details

I. General information

NPI: 1629555115
Provider Name (Legal Business Name): KIMBERLY PEORO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
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: 34-944-3145
  • Fax: 503-346-6810
Mailing address:
  • Phone: 503-494-4314
  • Fax: 503-346-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA195602
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: