Healthcare Provider Details

I. General information

NPI: 1447984893
Provider Name (Legal Business Name): SAMANTHA G SHOPOVICK AU-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date: 07/01/2026
Reactivation Date: 07/28/2026

III. Provider practice location address

4701 CREEDMOOR RD STE 111
RALEIGH NC
27612-4500
US

IV. Provider business mailing address

4701 CREEDMOOR RD STE 111
RALEIGH NC
27612-4500
US

V. Phone/Fax

Practice location:
  • Phone: 919-256-2898
  • Fax: 919-573-0889
Mailing address:
  • Phone: 919-256-2898
  • Fax: 919-573-0889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number30001998
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: