Provider Demographics
NPI:1043499890
Name:SAMPSON, SHARON (PT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 S HOUSE ROCK CIR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8336
Mailing Address - Country:US
Mailing Address - Phone:208-552-0226
Mailing Address - Fax:208-247-7777
Practice Address - Street 1:5412 S HOUSE ROCK CIR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-8336
Practice Address - Country:US
Practice Address - Phone:208-552-0226
Practice Address - Fax:208-247-7777
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist