Healthcare Provider Details

I. General information

NPI: 1861407363
Provider Name (Legal Business Name): ILEANA MARIA ESQUIVEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD L353
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: 503-494-7820
  • Fax:
Mailing address:
  • Phone: 503-494-8607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00932
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: