Basic Information
| Provider Information | |||||||||
| NPI: | 1790763282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWBOULD | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4112 HARBOUR POINTE BLVD SW | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253476330 | ||||||||
| FaxNumber: | 4253476335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD24750 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P1479 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60611291 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 294832501 | 05 | TX | MEDICAID | 297480 | 05 | OR | MEDICAID | 294832502 | 05 | TX | MEDICAID |