Healthcare Provider Details

I. General information

NPI: 1104385426
Provider Name (Legal Business Name): SAMANTHA YASUEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2019
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MULLINS DR
LEBANON OR
97355-3983
US

IV. Provider business mailing address

200 MULLINS DR
LEBANON OR
97355-3983
US

V. Phone/Fax

Practice location:
  • Phone: 541-259-0235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number23481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: