Healthcare Provider Details

I. General information

NPI: 1922061191
Provider Name (Legal Business Name): SAMUEL R. PETTIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742B BOYLSTON AVE E
SEATTLE WA
98102-4619
US

IV. Provider business mailing address

742B BOYLSTON AVE E
SEATTLE WA
98102-4619
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD00017597
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: