Healthcare Provider Details

I. General information

NPI: 1457041154
Provider Name (Legal Business Name): JACOB SALDIVAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5308 N LOMBARD ST
PORTLAND OR
97203-4218
US

IV. Provider business mailing address

PO BOX 2908
PORTLAND OR
97208-2908
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax: 971-282-0085
Mailing address:
  • Phone: 425-207-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA223193
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: