MEDICARE: VIRGINIA FONASH SAMHOURI CRNP

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	363LG0600X	Gerontology Nurse Practitioner	UP006861H	PA

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
2	0000910336	OTHER	PA	KHPE

General Provider Information

NPI Number	:	1932131950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA FONASH SAMHOURI CRNP

Provider Business Mailing Address
First Line	:	1394 TANGLEWOOD DR
Second Line	:
City	:	NORTH WALES
State	:	PA
Zip	:	19454-3677
Country	:	US
Telephone Number	:	215-699-8199
Fax Number	:

Provider Business Practice Location Address
First Line	:	2137 WELSH RD
Second Line	:	SUITE 1-C
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-4963
Country	:	US
Telephone Number	:	215-969-3944
Fax Number	:	215-969-3886

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/08/2007

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