Provider Demographics
NPI:1689457830
Name:HENRY, SAMANTHA LEANN (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEANN
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2151
Mailing Address - Country:US
Mailing Address - Phone:503-363-8047
Mailing Address - Fax:
Practice Address - Street 1:2485 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2151
Practice Address - Country:US
Practice Address - Phone:503-363-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA218183363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty