Provider Demographics
NPI:1104224047
Name:FERGUSON, SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W BAY DR NW STE 301
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4957
Mailing Address - Country:US
Mailing Address - Phone:360-413-8670
Mailing Address - Fax:360-413-8839
Practice Address - Street 1:304 W BAY DR NW STE 301
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4957
Practice Address - Country:US
Practice Address - Phone:360-413-8670
Practice Address - Fax:360-413-8839
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60520512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant