Basic Information
| Provider Information | |||||||||
| NPI: | 1821607300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MBUA | ||||||||
| FirstName: | SAMWEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MBUA | ||||||||
| OtherFirstName: | SAMWEL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16110 8TH AVE SW STE A2 | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981662962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062461012 | ||||||||
| FaxNumber: | 2062424437 | ||||||||
| Practice Location | |||||||||
| Address1: | 16110 8TH AVE SW STE A2 | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981662962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062461012 | ||||||||
| FaxNumber: | 2062424437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2020 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP61086528 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | AP61086528 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | AP61086528 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2167945 | 05 | WA | MEDICAID |