Basic Information
Provider Information | |||||||||
NPI: | 1700034907 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARNAHAN | ||||||||
FirstName: | CLAYTON | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRIGGS-CARNAHAN | ||||||||
OtherFirstName: | CLAYTON | ||||||||
OtherMiddleName: | JAMES | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11782 SW BARNES RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972255914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032145200 | ||||||||
FaxNumber: | 5039066613 | ||||||||
Practice Location | |||||||||
Address1: | 11782 SW BARNES RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972255914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032145200 | ||||||||
FaxNumber: | 5039066613 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2008 | ||||||||
LastUpdateDate: | 05/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01387 | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X | PA01387 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 500608548 | 05 | OR |   | MEDICAID | PA01387 | 01 | OR | PA LICENSE | OTHER |