Provider Demographics
NPI:1871242628
Name:LANADE, SAMSON O JR (PTA)
Entity Type:Individual
Prefix:
First Name:SAMSON
Middle Name:O
Last Name:LANADE
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP STE 604
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4403
Mailing Address - Country:US
Mailing Address - Phone:731-660-8781
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:587 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3938
Practice Address - Country:US
Practice Address - Phone:731-421-6510
Practice Address - Fax:731-421-6515
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN7502225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant