Provider Demographics
NPI:1518570738
Name:WILLIAMSON, SAMANTHA LARELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LARELLE
Last Name:WILLIAMSON
Suffix:
Gender:F
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:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:300 N GRAHAM ST STE 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-413-3714
Practice Address - Fax:503-413-2061
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA201539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant