Provider Demographics
NPI:1467221424
Name:BRODERSEN, SAMUEL EGAN
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:EGAN
Last Name:BRODERSEN
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 1:7107 NE 62ND ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-1965
Mailing Address - Country:US
Mailing Address - Phone:702-788-1073
Mailing Address - Fax:
Practice Address - Street 1:2149 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1580
Practice Address - Country:US
Practice Address - Phone:503-281-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26895225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist