Provider Demographics
NPI:1568153773
Name:WONSANG, SAMUEL ANTHONY (IDHS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANTHONY
Last Name:WONSANG
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15100 RESCUE WAY
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3502
Mailing Address - Country:US
Mailing Address - Phone:727-535-1437
Mailing Address - Fax:
Practice Address - Street 1:15100 RESCUE WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3502
Practice Address - Country:US
Practice Address - Phone:727-535-1437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman