Provider Demographics
NPI:1295515377
Name:WAITHAKA, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WAITHAKA
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 1:5702 99TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1082
Mailing Address - Country:US
Mailing Address - Phone:253-434-6821
Mailing Address - Fax:
Practice Address - Street 1:5702 99TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1082
Practice Address - Country:US
Practice Address - Phone:253-434-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD14093C172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver