MEDICARE: SAM URSA BEACH HAWTHORN LDM, LM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	MW60477681	WA
2	176B00000X	Midwife	DEM-LD-10160095	OR

General Provider Information

NPI Number	:	1073764536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAM URSA BEACH HAWTHORN LDM, LM

Provider Business Mailing Address
First Line	:	3205 NE 78TH ST STE 101
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98665-0697
Country	:	US
Telephone Number	:	503-395-4736
Fax Number	:

Provider Business Practice Location Address
First Line	:	3205 NE 78TH ST STE 101
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98665-0697
Country	:	US
Telephone Number	:	503-395-4736
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2008
Last Update Date	:	02/16/2026

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