Provider Demographics
NPI:1760012181
Name:YEAGY, SAMANTHA GAYLE (ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAYLE
Last Name:YEAGY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 S E 00 W
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:IN
Mailing Address - Zip Code:46928-9318
Mailing Address - Country:US
Mailing Address - Phone:765-618-3279
Mailing Address - Fax:
Practice Address - Street 1:11700 S E 00 W
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT
Practice Address - State:IN
Practice Address - Zip Code:46928-9318
Practice Address - Country:US
Practice Address - Phone:765-618-3279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002191A207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine