=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245755016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN MITCHELL SAMPSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2017
-----------------------------------------------------
Last Update Date | 11/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 PARNASSUS AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94143-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-514-1714
-----------------------------------------------------
Fax | 415-476-9516
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 PARNASSUS AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94143-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-514-1714
-----------------------------------------------------
Fax | 415-476-9516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 757965
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 699562
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 95002223
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------