Provider Demographics
NPI:1588090914
Name:UN, SAMRETH (LMP)
Entity type:Individual
Prefix:
First Name:SAMRETH
Middle Name:
Last Name:UN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18205 ALDERWOOD MALL PKWY STE K
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-3913
Mailing Address - Country:US
Mailing Address - Phone:425-778-1188
Mailing Address - Fax:
Practice Address - Street 1:18205 ALDERWOOD MALL PKWY STE K
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-3913
Practice Address - Country:US
Practice Address - Phone:425-778-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60238141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist