MEDICARE: KATHRYN B SAMPLES P.A.-C.

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	363AS0400X	Surgical Physician Assistant	003055	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386628790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN B SAMPLES P.A.-C.

Provider Business Mailing Address
First Line	:	119 AMBULANCE DR
Second Line	:	SUITE 202
City	:	CARROLLTON
State	:	GA
Zip	:	30117-3857
Country	:	US
Telephone Number	:	770-838-8710
Fax Number	:

Provider Business Practice Location Address
First Line	:	157 CLINIC AVE
Second Line	:	SUITE 302
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4413
Country	:	US
Telephone Number	:	770-834-3336
Fax Number	:	770-832-2136

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	01/27/2016

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