Provider Demographics
NPI:1700417466
Name:GWIN, SAMANTHA RAE (AGACNP-BC, APRN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:GWIN
Suffix:
Gender:F
Credentials:AGACNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 JOE RAMSEY BLVD E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7852
Mailing Address - Country:US
Mailing Address - Phone:903-408-5722
Mailing Address - Fax:
Practice Address - Street 1:4215 JOE RAMSEY BLVD E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7852
Practice Address - Country:US
Practice Address - Phone:903-408-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144891363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty