Provider Demographics
NPI:1558883868
Name:FLETCHER, SAMUEL JASON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JASON
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 TWILIGHT CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-7636
Mailing Address - Country:US
Mailing Address - Phone:229-220-5565
Mailing Address - Fax:
Practice Address - Street 1:5470 MERIDIAN MARKS RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:800-474-4007
Practice Address - Fax:800-474-4039
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN178608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty