Provider Demographics
NPI:1962587782
Name:ROSKAM, SARAH JAYNE
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JAYNE
Last Name:ROSKAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ROSHAM
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 N 205TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3215
Practice Address - Country:US
Practice Address - Phone:206-542-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8192957Medicaid
3908OtherINTERNAL ID-MOTOR VEHICLE ID
3908OtherINTERNAL ID-MOTOR VEHICLE ID
121321Medicare ID - Type Unspecified