Provider Demographics
NPI:1740474089
Name:SAM, DELORES MARIE (MT)
Entity type:Individual
Prefix:MS
First Name:DELORES
Middle Name:MARIE
Last Name:SAM
Suffix:
Gender:F
Credentials:MT
Other - Prefix:MR
Other - First Name:DELORES
Other - Middle Name:MARIE
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:515 SHOSHONE CIR
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-5072
Mailing Address - Country:US
Mailing Address - Phone:775-738-2252
Mailing Address - Fax:775-738-4219
Practice Address - Street 1:515 SHOSHONE CIR
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-5072
Practice Address - Country:US
Practice Address - Phone:775-738-2252
Practice Address - Fax:775-738-4219
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCNA018155247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician