Provider Demographics
NPI:1023748621
Name:GODIN, SAMUEL (NP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GODIN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 NW MYHRE RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7662
Mailing Address - Country:US
Mailing Address - Phone:564-240-4200
Mailing Address - Fax:564-240-4299
Practice Address - Street 1:1950 NW MYHRE RD FL 3
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7662
Practice Address - Country:US
Practice Address - Phone:564-240-4200
Practice Address - Fax:564-240-4299
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP6129808363LG0600X
WAAP61298808363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2212414Medicaid