Provider Demographics
NPI:1437133261
Name:MAESTAS, JENNIFER LEE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MAESTAS
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 1:4103 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2556
Mailing Address - Country:US
Mailing Address - Phone:503-850-9940
Mailing Address - Fax:877-533-6717
Practice Address - Street 1:4103 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2556
Practice Address - Country:US
Practice Address - Phone:503-850-9940
Practice Address - Fax:877-533-6717
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA153569363A00000X
OR153569363AS0400X
CO1515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63753286Medicaid
COP00231438OtherMEDICARE RAILROAD CARRIER
ORR157446Medicare PIN
COP56308Medicare UPIN
CO63753286Medicaid