Provider Demographics
NPI:1497830426
Name:SAMPSON, GREGG ORVILLE (PT)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:ORVILLE
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:360-337-7662
Mailing Address - Fax:360-337-7300
Practice Address - Street 1:1015 NE HOSTMARK ST
Practice Address - Street 2:SUITE #101
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6204
Practice Address - Country:US
Practice Address - Phone:360-697-7726
Practice Address - Fax:360-697-7728
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91181639721OtherKPS
WA9187607OtherCIGNA
WA8345118Medicaid
WA8345118Medicaid