Healthcare Provider Details

I. General information

NPI: 1912377169
Provider Name (Legal Business Name): SAMUEL BAWCUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4259 23RD AVE W STE 200
SEATTLE WA
98199-1534
US

IV. Provider business mailing address

510 BRYN MAWR DR SE
ALBUQUERQUE NM
87106-2302
US

V. Phone/Fax

Practice location:
  • Phone: 206-686-4878
  • Fax:
Mailing address:
  • Phone: 505-710-8418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number26031
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: