Provider Demographics
NPI:1093444317
Name:SAMATAR, AMAL
Entity type:Individual
Prefix:
First Name:AMAL
Middle Name:
Last Name:SAMATAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18330 NE 99TH WAY
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-6902
Mailing Address - Country:US
Mailing Address - Phone:707-479-4818
Mailing Address - Fax:
Practice Address - Street 1:114 PIONEER TRL
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1167
Practice Address - Country:US
Practice Address - Phone:952-361-6855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61320745122300000X
WADE61320745122300000X
390200000X
MND15168122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program