Provider Demographics
NPI:1003439084
Name:VALDIVIA, SAMUEL BRYAN
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BRYAN
Last Name:VALDIVIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SW COLUMBIA ST APT 404
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-2592
Mailing Address - Country:US
Mailing Address - Phone:602-403-5363
Mailing Address - Fax:
Practice Address - Street 1:501 N GRAHAM ST MEDICAL OFFICE BUILDING 2
Practice Address - Street 2:SUITE 220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-413-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-25
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA213719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program