Provider Demographics
NPI:1912377169
Name:BAWCUM, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:BAWCUM
Suffix:
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 1:510 BRYN MAWR DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2302
Mailing Address - Country:US
Mailing Address - Phone:505-710-8418
Mailing Address - Fax:
Practice Address - Street 1:4259 23RD AVE W
Practice Address - Street 2:STE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-1534
Practice Address - Country:US
Practice Address - Phone:206-686-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM26031146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic