Provider Demographics
NPI:1285802850
Name:HAUPTMAN, JACOB PETER (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PETER
Last Name:HAUPTMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 NE 99TH AVE
Mailing Address - Street 2:#200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-9436
Mailing Address - Country:US
Mailing Address - Phone:503-215-4250
Mailing Address - Fax:
Practice Address - Street 1:1321 NE 99TH AVE
Practice Address - Street 2:#200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9436
Practice Address - Country:US
Practice Address - Phone:503-215-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20495363AM0700X
CT002042363AM0700X
OR161825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical