Provider Demographics
NPI:1457918583
Name:MCPHERSON, SAMANTHA JO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:MCPHERSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 RIACHUELO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-4039
Mailing Address - Country:US
Mailing Address - Phone:949-303-3233
Mailing Address - Fax:
Practice Address - Street 1:3900 FIFTH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3122
Practice Address - Country:US
Practice Address - Phone:858-544-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner