Provider Demographics
NPI:1386860492
Name:PETTIBON, SAM L (DO)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:L
Last Name:PETTIBON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30804 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4902
Mailing Address - Country:US
Mailing Address - Phone:253-839-5644
Mailing Address - Fax:253-839-2625
Practice Address - Street 1:30804 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4902
Practice Address - Country:US
Practice Address - Phone:253-839-5644
Practice Address - Fax:253-839-2625
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2174111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPE5678OtherREGENCE INSURANCE PROVIDE
WA2007078Medicaid
WA73321OtherL & I PROVIDER
WA73321OtherL & I PROVIDER
WA000106746Medicare ID - Type Unspecified