Basic Information
| Provider Information | |||||||||
| NPI: | 1477988467 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTENSEN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | M. K. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413822811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE. | ||||||||
| Address2: | MAIL CODE: CH16D | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034944713 | ||||||||
| FaxNumber: | 5034946968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA165137 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 500663953 | 05 | OR | MEDICAID |