Basic Information
| Provider Information | |||||||||
| NPI: | 1639646128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALELA | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | RACHELLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 116TH AVE NE STE 305 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254531772 | ||||||||
| FaxNumber: | 4254530603 | ||||||||
| Practice Location | |||||||||
| Address1: | 4011 TALBOT RD S STE 420 | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903456 | ||||||||
| FaxNumber: | 4256909456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 60908087 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60908087 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2155852 | 05 | WA | MEDICAID |