Healthcare Provider Details

I. General information

NPI: 1255977492
Provider Name (Legal Business Name): SAMANTHA SHAW MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA KRAGE MSN, APRN, FNP-C

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 E BELL RD STE 2400
PHOENIX AZ
85032-2181
US

IV. Provider business mailing address

11510 E RANCH GATE RD
SCOTTSDALE AZ
85255-8235
US

V. Phone/Fax

Practice location:
  • Phone: 833-696-3349
  • Fax:
Mailing address:
  • Phone: 904-599-3209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number264757
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN214222
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-161951
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: