Provider Demographics
NPI:1518191600
Name:BAZAN, SAMANTHA E (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:E
Last Name:BAZAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:E
Other - Last Name:LESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6965
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001191133163WC1500X, 390200000X
VA0024174619363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program