=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528420429
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLASTIC SURGERY ASSOCIATES OF TIDEWATER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2016
-----------------------------------------------------
Last Update Date | 03/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5818 HARBOUR VIEW BLVD SUITE 200
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-673-6000
-----------------------------------------------------
Fax | 757-673-6007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5818 HARBOUR VIEW BLVD SUITE 200
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-673-6000
-----------------------------------------------------
Fax | 757-673-6007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. SAMANTHA MARIE PERSSON
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 540-493-7759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024173410
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------