Provider Demographics
NPI:1649782699
Name:PUTNAM, CARLEY (PA-C)
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:PUTNAM
Suffix:
Gender:F
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 1:1650 NW NAITO PKWY STE 185
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2535
Mailing Address - Country:US
Mailing Address - Phone:503-525-7658
Mailing Address - Fax:
Practice Address - Street 1:3303 SW BOND AVE STE 5
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-6687
Practice Address - Fax:503-494-1717
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA187398363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant