Provider Demographics
NPI:1043855257
Name:ABBOTT, SAMANTHA JAY (FNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JAY
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ABBOTT
Other - Last Name:CHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2302
Mailing Address - Country:US
Mailing Address - Phone:503-941-3077
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE STE 325
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6656
Practice Address - Country:US
Practice Address - Phone:503-416-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201909196NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500772549Medicaid