Healthcare Provider Details

I. General information

NPI: 1275315525
Provider Name (Legal Business Name): SAMUEL WILLIAM PACKHAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 LIBERTY ST SE STE 200
SALEM OR
97302-4195
US

IV. Provider business mailing address

2957 GLEN EAGLES RD
LAKE OSWEGO OR
97034-2737
US

V. Phone/Fax

Practice location:
  • Phone: 503-399-0652
  • Fax:
Mailing address:
  • Phone: 971-386-8399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA222588
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: