Provider Demographics
NPI:1457041154
Name:SALDIVAR, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SALDIVAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2908
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2908
Mailing Address - Country:US
Mailing Address - Phone:425-207-5155
Mailing Address - Fax:
Practice Address - Street 1:5308 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4218
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:971-282-0085
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA223193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant