Provider Demographics
NPI:1659562536
Name:CLAYTON, LARA ANNA (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ANNA
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:ANNA
Other - Last Name:LEGRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-3376
Mailing Address - Fax:503-494-6968
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:CH16D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-418-3376
Practice Address - Fax:503-494-6968
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA164160363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant