=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235092982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL PATTERSON LPTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2025
-----------------------------------------------------
Last Update Date | 12/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4347 W GAY RD
-----------------------------------------------------
City | DIBERVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39540-3412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-392-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 W MCHENRY RD
-----------------------------------------------------
City | PERKINSTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39573-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA7918
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------