Provider Demographics
NPI:1053819755
Name:SAM, IMELDA CHI (NP-C)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:CHI
Last Name:SAM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-4400
Mailing Address - Country:US
Mailing Address - Phone:702-791-9000
Mailing Address - Fax:
Practice Address - Street 1:3968 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3412
Practice Address - Country:US
Practice Address - Phone:702-791-9020
Practice Address - Fax:702-791-9261
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN00002763363LG0600X
NVAPRN002763363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology