Provider Demographics
NPI:1174743124
Name:SAMPSON, JOHANNA HADLEY (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:HADLEY
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WADE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-3121
Mailing Address - Country:US
Mailing Address - Phone:919-228-8155
Mailing Address - Fax:984-220-9276
Practice Address - Street 1:600 WADE AVE STE A
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-3121
Practice Address - Country:US
Practice Address - Phone:919-228-8155
Practice Address - Fax:984-220-9276
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2075348Medicare UPIN
NC2347843Medicare PIN