Individual ProviderSamuel MoodyPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address3181 SW Sam Jackson Park Rd, Portland, OR 97239-3011(503) 494-6596(866) 617-6855PECOS EnrollmentBased on the most recent information from CMS, provider Samuel Moody is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1710655584Provider TypeIndividualFull NameMoody, SamuelCredentialPA-CGenderMaleSole ProprietorNoEnumeration Date9/5/2021Last Updated1/9/2024Contact InformationPractice LocationPractice Address3181 SW Sam Jackson Park Rd, Portland, OR 97239-3011Phone(503) 494-6596Fax(503) 494-4285Mailing LocationMailing Address1400 SW 5th Ave Ste 500, Portland, OR 97201-5537Phone(866) 617-6855Fax(503) 346-8015Provider TaxonomiesCodeDescriptionLicenseCode363AM0700XPrimaryDescriptionPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersLicensePA217671Oregon