Provider Demographics
NPI:1447084587
Name:TRAVIS, SAMANTHA R (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:TRAVIS
Suffix:
Gender:
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:9427 SW BARNES RD STE 593
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6640
Practice Address - Country:US
Practice Address - Phone:503-216-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA222607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant