Healthcare Provider Details

I. General information

NPI: 1114102597
Provider Name (Legal Business Name): SUSAN M SAMSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 WASHINGTON AVE STE 101
ALBANY NY
12206-1056
US

IV. Provider business mailing address

449 ROUTE 146 STE 101
HALFMOON NY
12065-3239
US

V. Phone/Fax

Practice location:
  • Phone: 518-438-4483
  • Fax:
Mailing address:
  • Phone: 518-373-3924
  • Fax: 518-373-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF331316
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: