Provider Demographics
NPI:1164462990
Name:DE MENEZES, JURANDIR B JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:JURANDIR
Middle Name:B
Last Name:DE MENEZES
Suffix:JR
Gender:M
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 NW SAMARITAN DR
Practice Address - Street 2:STE 201
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3771
Practice Address - Country:US
Practice Address - Phone:541-768-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60041664363AS0400X
ORPA01048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0253647OtherL&I
WA8884452Medicare PIN