Healthcare Provider Details

I. General information

NPI: 1053840694
Provider Name (Legal Business Name): SAN SAEPHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3639 MARTIN LUTHER KING JR WAY S
SEATTLE WA
98144-6847
US

IV. Provider business mailing address

3639 MARTIN LUTHER KING JR WAY S
SEATTLE WA
98144-6847
US

V. Phone/Fax

Practice location:
  • Phone: 206-774-2419
  • Fax:
Mailing address:
  • Phone: 206-774-2419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: