Basic Information
| Provider Information | |||||||||
| NPI: | 1144414046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAVER | ||||||||
| FirstName: | KENRIC | ||||||||
| MiddleName: | BRION | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18040 SW LOWER BOONES FERRY RD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032160700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA01296 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA01296 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.