Healthcare Provider Details

I. General information

NPI: 1275345266
Provider Name (Legal Business Name): DEVYN ROSS SAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 S HIGHWAY 25 W
WILLIAMSBURG KY
40769-1639
US

IV. Provider business mailing address

107 S MAIN ST
JELLICO TN
37762-2154
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-2656
  • Fax:
Mailing address:
  • Phone: 423-784-8492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC044
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: