Provider Demographics
NPI:1295135275
Name:SAMPSON, MIRKO
Entity type:Individual
Prefix:
First Name:MIRKO
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 N 3600 W
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:WEBER STATE UNIVERSITY
Practice Address - Street 2:1435 VILLAGE DRIVE, DEPT. 2801
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-2801
Practice Address - Country:US
Practice Address - Phone:850-226-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer