MEDICARE: SAMUEL LECATES CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	110650	NC
2	367500000X	Certified Registered Nurse Anesthetist	151711	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790788396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL LECATES CRNA

Provider Business Mailing Address
First Line	:	PO BOX 14489
Second Line	:
City	:	ARCHDALE
State	:	NC
Zip	:	27263-7489
Country	:	US
Telephone Number	:	800-277-8151
Fax Number	:	336-841-6217

Provider Business Practice Location Address
First Line	:	1834 GRAVES MILL RD
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551
Country	:	US
Telephone Number	:	800-277-8151
Fax Number	:	336-841-6217

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	08/04/2009

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