Healthcare Provider Details

I. General information

NPI: 1710617550
Provider Name (Legal Business Name): SAMANTHA TAYLOR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2747 NE CONNERS AVE
BEND OR
97701-8738
US

IV. Provider business mailing address

2747 NE CONNERS AVE
BEND OR
97701-8738
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-5712
  • Fax: 541-382-2605
Mailing address:
  • Phone: 541-382-5712
  • Fax: 541-382-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA209982
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: