Provider Demographics
NPI:1699320846
Name:SAMUEL-JOHN, MARYAM (LAC)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:SAMUEL-JOHN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 MOLALLA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-3772
Mailing Address - Country:US
Mailing Address - Phone:503-765-7324
Mailing Address - Fax:503-765-7308
Practice Address - Street 1:1017 MOLALLA AVE STE 2
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3772
Practice Address - Country:US
Practice Address - Phone:503-765-7324
Practice Address - Fax:503-765-7308
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60843753171100000X
ORAC198434171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist