Provider Demographics
NPI:1205475670
Name:SAMSON, MIRANDA WHITLEY
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:WHITLEY
Last Name:SAMSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 DRY CREEK DR STE 204
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7748
Mailing Address - Country:US
Mailing Address - Phone:303-938-1141
Mailing Address - Fax:
Practice Address - Street 1:1325 DRY CREEK DR STE 204
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7748
Practice Address - Country:US
Practice Address - Phone:303-938-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0016778208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTL.0016778OtherCOLORADO PHYSICAL THERAPY LICENSE