MEDICARE: SIA SAM-SUMANA

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	363LF0000X	Family Nurse Practitioner	5020304	NC

General Provider Information

NPI Number	:	1740026483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIA SAM-SUMANA

Provider Business Mailing Address
First Line	:	29 CASTELLO WAY
Second Line	:
City	:	CLAYTON
State	:	NC
Zip	:	27527-5429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3616 CAPE CENTER DR STE A
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4456
Country	:	US
Telephone Number	:	910-779-0780
Fax Number	:

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

Provider Enumeration Date	:	07/02/2024
Last Update Date	:	07/02/2024

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Directions to “ SIA SAM-SUMANA ” Practice Location

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