Provider Demographics
NPI:1164830212
Name:MESA, KENDRA D (PA)
Entity type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:D
Last Name:MESA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:KENDRA
Other - Middle Name:D
Other - Last Name:PREILIPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:60 S 11TH CT
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-9386
Mailing Address - Country:US
Mailing Address - Phone:239-218-6724
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD # ED
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7551
Practice Address - Fax:503-494-4997
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA209206363AM0700X
WAPA60493784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8932822Medicare PIN