Healthcare Provider Details

I. General information

NPI: 1154181022
Provider Name (Legal Business Name): SAMUEL LWANYAGA AGPCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 HERITAGE VILLAGE PLZ
GAINESVILLE VA
20155-3078
US

IV. Provider business mailing address

10211 WATERBURY CT
MANASSAS VA
20110-6143
US

V. Phone/Fax

Practice location:
  • Phone: 157-150-5285
  • Fax: 571-248-6455
Mailing address:
  • Phone: 157-505-2853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024189728
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: