Provider Demographics
NPI:1407445836
Name:NIGRA, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:NIGRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15204 WILDERNESS RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4146
Mailing Address - Country:US
Mailing Address - Phone:276-791-5557
Mailing Address - Fax:
Practice Address - Street 1:15204 WILDERNESS RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4146
Practice Address - Country:US
Practice Address - Phone:276-791-5557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer