Basic Information
| Provider Information | |||||||||
| NPI: | 1386976041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRIS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | IDMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 HOSPITAL LOOP | ||||||||
| Address2: | |||||||||
| City: | FAIRCHILD AFB | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990118704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092475755 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 HOSPITAL LOOP | ||||||||
| Address2: | |||||||||
| City: | FAIRCHILD AFB | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990118704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092475755 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2010 | ||||||||
| LastUpdateDate: | 04/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1003X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Medical Technicians |
No ID Information.