Provider Demographics
NPI:1114608817
Name:ROSETTE CAMERON, KYLEE ANN
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:ANN
Last Name:ROSETTE CAMERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:ANN
Other - Last Name:ROSETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12345 SW 131ST AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-7821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
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:503-418-5750
Practice Address - Fax:503-418-5793
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA216028363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical