Organization
SOUTHEAST UROLOGY CLINIC A PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. EVA M SAMTMANA (AMINISTRATOR)
(360) 424-7991
Entity
Organization
Contact information
Practice address
3100 TONGASS AVE, KETCHIKAN, AK 99901-5746
(907) 225-1896
(360) 428-4377
Mailing address
1311 E DIVISION ST, MOUNT VERNON, WA 98274
(360) 424-7991
(360) 424-5441
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
121467
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0126
—
AK
Enumeration date
09/26/2006
Last updated
08/09/2010
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