Provider Demographics
NPI:1972092211
Name:SAMAAN, MARINA
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:
Last Name:SAMAAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083-1710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-1710
Practice Address - Country:US
Practice Address - Phone:615-666-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621862929Medicaid