Healthcare Provider Details

I. General information

NPI: 1104224047
Provider Name (Legal Business Name): SAMANTHA FERGUSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W BAY DR NW STE 301
OLYMPIA WA
98502-4957
US

IV. Provider business mailing address

304 W BAY DR NW STE 301
OLYMPIA WA
98502-4957
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-8670
  • Fax: 360-413-8839
Mailing address:
  • Phone: 360-413-8670
  • Fax: 360-413-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60520512
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: