Provider Demographics
NPI:1265029185
Name:SAMS, JOHN BONNER III
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BONNER
Last Name:SAMS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1125
Mailing Address - Country:US
Mailing Address - Phone:206-850-3478
Mailing Address - Fax:
Practice Address - Street 1:1715 15TH ST
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337-1125
Practice Address - Country:US
Practice Address - Phone:206-850-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60299798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty