Provider Demographics
NPI:1609232172
Name:BLACK, SAMANTHA GWEN (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GWEN
Last Name:BLACK
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 1:4400 GOLF ACRES DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5906
Mailing Address - Country:US
Mailing Address - Phone:704-512-6428
Mailing Address - Fax:
Practice Address - Street 1:201 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3917
Practice Address - Country:US
Practice Address - Phone:980-487-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC231559367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered