=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407809270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL JOSEPH HADLEY CSA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22834 SW FOREST CREEK DR APT #202
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97140-9874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-866-6955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22834 SW FOREST CREEK DR APT #202
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97140-9874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-866-6955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | NA
-----------------------------------------------------
License Number State |
-----------------------------------------------------