Provider Demographics
NPI:1508817602
Name:SAMSON, SHARON LESLIE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:LESLIE
Last Name:SAMSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:LESLIE ROSS
Other - Last Name:HORSFALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 CENTRE ON THE LAKE
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367
Mailing Address - Country:US
Mailing Address - Phone:636-625-4448
Mailing Address - Fax:636-625-4449
Practice Address - Street 1:50 CENTRE ON THE LAKE
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2938
Practice Address - Country:US
Practice Address - Phone:636-625-4448
Practice Address - Fax:636-625-4449
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
25141OtherGHP
192065OtherBLUE CROSS BLUE SHIELD
V03186Medicare UPIN
000025735Medicare ID - Type Unspecified