Provider Demographics
NPI:1376807776
Name:FAWCETT, SAMANTHA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:MAUTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2700 CLAY EDWARDS DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3251
Mailing Address - Country:US
Mailing Address - Phone:816-691-5287
Mailing Address - Fax:816-346-7690
Practice Address - Street 1:9411 N OAK TRFY
Practice Address - Street 2:SUITE 100
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2233
Practice Address - Country:US
Practice Address - Phone:816-436-1800
Practice Address - Fax:816-436-4241
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine