Healthcare Provider Details

I. General information

NPI: 1003608498
Provider Name (Legal Business Name): ERIC EDWIN SAMUELSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 SUNRISE BLVD STE A
GOLD RIVER CA
95670-4344
US

IV. Provider business mailing address

2485 SUNRISE BLVD STE A
GOLD RIVER CA
95670-4344
US

V. Phone/Fax

Practice location:
  • Phone: 916-642-1867
  • Fax:
Mailing address:
  • Phone: 630-999-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95035816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: