Provider Demographics
NPI:1891797361
Name:SAMPSON, MARTHA LAROSE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LAROSE
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:LAROSESAMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CR NA
Mailing Address - Street 1:258 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-1423
Mailing Address - Country:US
Mailing Address - Phone:508-865-0262
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3271
Practice Address - Fax:508-856-5911
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN115845367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA020501Medicare PIN