Provider Demographics
NPI:1063124709
Name:RILEY, SAMANTHA JANE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9617 N FISKE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-2012
Mailing Address - Country:US
Mailing Address - Phone:971-293-1072
Mailing Address - Fax:
Practice Address - Street 1:30 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2941
Practice Address - Country:US
Practice Address - Phone:503-232-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000107596175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist