Provider Demographics
NPI:1083244073
Name:RASMUSSEN, SAMIRAT AMA
Entity Type:Individual
Prefix:
First Name:SAMIRAT
Middle Name:AMA
Last Name:RASMUSSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9730 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2827
Mailing Address - Country:US
Mailing Address - Phone:404-996-9466
Mailing Address - Fax:678-404-7624
Practice Address - Street 1:9730 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2827
Practice Address - Country:US
Practice Address - Phone:404-996-9466
Practice Address - Fax:678-404-7624
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP0105472278H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHCP010547Medicaid