Provider Demographics
NPI:1952794687
Name:ITIE, SAMUEL BASIAKA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BASIAKA
Last Name:ITIE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 W HOBBS ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-3646
Mailing Address - Country:US
Mailing Address - Phone:575-623-5263
Mailing Address - Fax:575-623-5286
Practice Address - Street 1:712 W HOBBS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-3646
Practice Address - Country:US
Practice Address - Phone:575-623-5263
Practice Address - Fax:575-623-5286
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127554363LF0000X
NM69489363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health