Provider Demographics
NPI:1477988467
Name:CHRISTENSEN, SAMUEL M K (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M K
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6051
Mailing Address - Country:US
Mailing Address - Phone:541-382-2811
Mailing Address - Fax:
Practice Address - Street 1:3303 SW BOND AVE.
Practice Address - Street 2:MAIL CODE: CH16D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-4713
Practice Address - Fax:503-494-6968
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA165137363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500663953Medicaid
OR500663953Medicaid