Provider Demographics
NPI:1053684332
Name:ADDISON, SAMANTHA G (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:G
Last Name:ADDISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:280 VIRGINIA AVE NE
Practice Address - Street 2:SUITE 107
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1538
Practice Address - Country:US
Practice Address - Phone:276-679-5390
Practice Address - Fax:276-679-5395
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAV V5014BMedicare PIN
VAV V5014AMedicare PIN