Healthcare Provider Details

I. General information

NPI: 1235092982
Provider Name (Legal Business Name): SAMUEL PATTERSON LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4347 W GAY RD
DIBERVILLE MS
39540-3412
US

IV. Provider business mailing address

318 W MCHENRY RD
PERKINSTON MS
39573-3346
US

V. Phone/Fax

Practice location:
  • Phone: 228-392-8484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA7918
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: