Healthcare Provider Details

I. General information

NPI: 1194451971
Provider Name (Legal Business Name): SAMUEL FRAZIER APRN, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 109
GRESHAM OR
97030-3381
US

IV. Provider business mailing address

2603 CARLOW DR
AUSTIN TX
78745-4346
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-7162
  • Fax:
Mailing address:
  • Phone: 512-507-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number1087151
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number10037912
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: