Provider Demographics
NPI:1588934442
Name:STREET, KAYLA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:STREET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4729
Mailing Address - Country:US
Mailing Address - Phone:503-585-6388
Mailing Address - Fax:503-585-0669
Practice Address - Street 1:435 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4729
Practice Address - Country:US
Practice Address - Phone:503-585-6388
Practice Address - Fax:503-585-0669
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant