Provider Demographics
NPI:1790788396
Name:LECATES, SAMUEL (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:LECATES
Suffix:
Gender:M
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:PO BOX 14489
Mailing Address - Street 2:
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-7489
Mailing Address - Country:US
Mailing Address - Phone:800-277-8151
Mailing Address - Fax:336-841-6217
Practice Address - Street 1:1834 GRAVES MILL RD
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551
Practice Address - Country:US
Practice Address - Phone:800-277-8151
Practice Address - Fax:336-841-6217
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110650367500000X
VA151711367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010029601Medicaid
VA010029601Medicaid
NC2603195AMedicare ID - Type Unspecified