Healthcare Provider Details

I. General information

NPI: 1386070795
Provider Name (Legal Business Name): MR. SAMUEL WAINE OSWALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 NE COUCH ST
PORTLAND OR
97232-2922
US

IV. Provider business mailing address

6455 SW NYBERG LN APT H101
TUALATIN OR
97062-7450
US

V. Phone/Fax

Practice location:
  • Phone: 503-542-4603
  • Fax: 503-233-6093
Mailing address:
  • Phone: 503-805-5716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0177
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: