Basic Information
| Provider Information | |||||||||
| NPI: | 1134615446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASKEY | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | HALEY BURTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURTON | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | HAYLEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1003 7TH AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256583016 | ||||||||
| FaxNumber: | 4256583017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 7TH AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256583016 | ||||||||
| FaxNumber: | 4256583017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2018 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 106S00000X | CB60893736 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | 2111488 | 05 | WA | MEDICAID |