Provider Demographics
NPI:1689170375
Name:SAMUEL, SHINY (NP)
Entity Type:Individual
Prefix:
First Name:SHINY
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DEER ISLE CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-6465
Mailing Address - Country:US
Mailing Address - Phone:919-946-4059
Mailing Address - Fax:
Practice Address - Street 1:550 NEW WAVERLY PL STE 105
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7412
Practice Address - Country:US
Practice Address - Phone:919-233-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010430363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care