Provider Demographics
NPI:1487096442
Name:ELLER, SAMANTHA (MD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:3901 NE 4TH ST
Practice Address - Street 2:STE 105
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-4100
Practice Address - Country:US
Practice Address - Phone:425-690-3410
Practice Address - Fax:425-690-9410
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60648052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine