Healthcare Provider Details

I. General information

NPI: 1922731900
Provider Name (Legal Business Name): SAMANTHA NICOLE MOYER BSN, RN, MHS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 NEW BERN AVE
RALEIGH NC
27610-1214
US

IV. Provider business mailing address

PO BOX 603949
CHARLOTTE NC
28260-3949
US

V. Phone/Fax

Practice location:
  • Phone: 919-232-5020
  • Fax:
Mailing address:
  • Phone: 919-350-0351
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12589
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-12589
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number289332
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: