Provider Demographics
NPI:1801567359
Name:SAMUEL, SIJI (ANP)
Entity type:Individual
Prefix:
First Name:SIJI
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1505 LBJ FWY STE 700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6065
Mailing Address - Country:US
Mailing Address - Phone:214-358-2300
Mailing Address - Fax:214-579-6941
Practice Address - Street 1:411 N WASHINGTON AVE STE 6000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1789
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-579-6988
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1029999363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1029999OtherLICENSE