Provider Demographics
NPI:1508075896
Name:WEATHERFORD, SAMUEL H (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:H
Last Name:WEATHERFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MEDICAL VILLAGE DR STE F
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-1665
Mailing Address - Country:US
Mailing Address - Phone:910-285-0940
Mailing Address - Fax:910-285-1825
Practice Address - Street 1:112 MEDICAL VILLAGE DR STE F
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-1665
Practice Address - Country:US
Practice Address - Phone:910-285-0940
Practice Address - Fax:910-285-1825
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05179363A00000X, 363AM0700X
SC656363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical