Provider Demographics
NPI:1225622293
Name:WARD, KELLEY RUTH (PA-C)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:RUTH
Last Name:WARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:RUTH
Other - Last Name:GIROUARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:17055 RUBEN LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-9276
Mailing Address - Country:US
Mailing Address - Phone:503-668-8002
Mailing Address - Fax:
Practice Address - Street 1:17055 RUBEN LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-9276
Practice Address - Country:US
Practice Address - Phone:503-668-8002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-21
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
ORPA213070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program