Provider Demographics
NPI:1457359507
Name:EGGERTSEN, SAM CHILD (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:CHILD
Last Name:EGGERTSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E MEEKER ST
Mailing Address - Street 2:STE 300
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6016 NE BOTHELL WAY
Practice Address - Street 2:STE G
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-9403
Practice Address - Country:US
Practice Address - Phone:425-486-0658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine