NPIMap

Individual provider Active NPI

Kamylli J Mendive, PA-C

  • Physician Assistant
  • Tigard, OR
National Provider Identifier
1821653254
Registry record updated Sep 30, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA202793 Issued in OR
Practice address
12442 SW Scholls Ferry Rd Ste 100
Tigard, OR 97223-0803
Phone
(503) 216-9200
NPI assigned
May 1, 2019
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 58813 CA
Physician Assistant 363A00000X PA202793 OR Primary

Addresses

Primary practice location

12442 SW Scholls Ferry Rd Ste 100
Tigard, OR 97223-0803

Mailing address

PO Box 3158
Portland, OR 97208-3158
Phone (503) 215-6494

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA, OR2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20210125001799 CA Practitioner - Physician Assistant 8527472042 Reassigns benefits to 3 organizations
I20240710003192 OR Practitioner - Physician Assistant 8527472042 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Oregon Health Sciences University School of Medicine, 2020
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

12442 SW Scholls Ferry Rd
Suite 100
Tigard, OR 97223-0803
Phone (503) 215-9900

5050 NE Hoyt St
Suite 240
Portland, OR 97213-2981
Phone (503) 215-6480

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
58813CAMDDentist
PA202793ORMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Oregon CurrentSince Aug 12, 2024 Accepting new patients
Stat Med PC a California Medical Professional Corporation CurrentSince Mar 6, 2024 Accepting new patients
Stat Med PC a California Medical Professional Corporation CurrentSince Mar 6, 2024 Accepting new patients
Providence Health & Services - Oregon CurrentSince Aug 12, 2024 Accepting new patients
Cardinal Primary Care Medical Group, Inc PastSince Jan 1, 2021 Accepting new patients
UCSF Health Community Hospitals Past Accepting new patients

Locations

901 Sunvalley Blvd
Ste 100
Concord, CA 94520
Phone (925) 234-4447

5050 NE Hoyt St
Ste 240
Portland, OR 97213
Phone (503) 215-6480

12442 SW Scholls Ferry Rd
Ste 100
Tigard, OR 97223
Phone (503) 215-9900

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1556668800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1727654400000",
    "number": "1821653254",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158",
            "telephone_number": "503-215-6494"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12442 SW SCHOLLS FERRY RD STE 100",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972230803",
            "telephone_number": "503-216-9200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MENDIVE",
        "first_name": "KAMYLLI",
        "middle_name": "J",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-05-01",
        "last_updated": "2024-09-30",
        "certification_date": "2024-09-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "58813",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OR",
            "license": "PA202793",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tigard, OR

Sources for this page

Verify at the official NPI Registry.