Provider Demographics
NPI:1568402626
Name:BOSTIC, SAMANTHA SHAYNE (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SHAYNE
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-720-8816
Mailing Address - Fax:904-494-6467
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:904-494-6467
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48772367500000X
WVAPRN48772CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094458Medicaid
WV0207026000Medicaid
WV001845205OtherBCBS
WVDA0096OtherRR MEDICARE
WV001845205OtherBCBS-MAAC
WV001706470OtherMSBCBS GROUP
WVP00001166OtherRR MEDICARE
WV0069311000Medicaid
WV001706470OtherMSBCBS GROUP
WV0207026000Medicaid