Provider Demographics
NPI:1013403286
Name:SAMPSON, IAN B
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:B
Last Name:SAMPSON
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 1:46314 TIMINE WAY
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-9417
Mailing Address - Country:US
Mailing Address - Phone:541-966-9830
Mailing Address - Fax:541-278-7568
Practice Address - Street 1:46314 TIMINE WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-278-7568
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist