Healthcare Provider Details

I. General information

NPI: 1699064931
Provider Name (Legal Business Name): SAMER SEAD ELGEZAWI LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 SE 36TH ST SUITE 210
BELLEVUE WA
98006-1657
US

IV. Provider business mailing address

1 LAKE BELLEVUE DR SUITE 100
BELLEVUE WA
98005-2417
US

V. Phone/Fax

Practice location:
  • Phone: 425-653-7100
  • Fax: 425-653-7109
Mailing address:
  • Phone: 425-462-4330
  • Fax: 425-462-4335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60203268
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: