Provider Demographics
NPI:1184638629
Name:SAMUELS, NATHAN (NP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 HERRICK ST
Mailing Address - Street 2:STE 101
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-3012
Mailing Address - Country:US
Mailing Address - Phone:978-927-4110
Mailing Address - Fax:978-232-7057
Practice Address - Street 1:77 HERRICK ST
Practice Address - Street 2:STE 101
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-3012
Practice Address - Country:US
Practice Address - Phone:978-927-4110
Practice Address - Fax:978-232-7057
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANP258431363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP9661OtherBS
NP5234Medicare ID - Type Unspecified
O60202Medicare UPIN