MEDICARE: SAMANTHA LAINE HIGGERSON LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096.005226	IL
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2255A2300X	Athletic Trainer	2020031143	MO

General Provider Information

NPI Number	:	1043869977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LAINE HIGGERSON LAT, ATC

Provider Business Mailing Address
First Line	:	209 S KINGSHIGHWAY ST # 1700
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-1695
Country	:	US
Telephone Number	:	618-477-1676
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 S KINGSHIGHWAY ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-1695
Country	:	US
Telephone Number	:	618-477-1676
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	06/29/2021

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