Provider Demographics
NPI:1760077440
Name:ANDERSON, SAMANTHA RAE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:RAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27938-9551
Mailing Address - Country:US
Mailing Address - Phone:252-357-1379
Mailing Address - Fax:
Practice Address - Street 1:11 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27938-9551
Practice Address - Country:US
Practice Address - Phone:252-357-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2300665501225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant