Individual
KELLIE L GRAYBOSCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
9427 SW BARNES RD, STE 495, PORTLAND, OR 97225-6652
(503) 216-1661
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA156616
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500640073
—
OR
01
—
P01046628
RR MEDICARE (PH&S)
OR
Enumeration date
10/06/2011
Last updated
03/10/2021
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