Provider Demographics
NPI:1316120181
Name:WELBOURN, KAYLEEN MARIE (PA)
Entity type:Individual
Prefix:
First Name:KAYLEEN
Middle Name:MARIE
Last Name:WELBOURN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAYLEEN
Other - Middle Name:MARIE
Other - Last Name:CARNAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:11782 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5933
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:503-906-6613
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01313363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604994Medicaid
WA1057309Medicaid