Basic Information
| Provider Information | |||||||||
| NPI: | 1033887021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VERGARA | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668900 | ||||||||
| FaxNumber: | 2602668936 | ||||||||
| Practice Location | |||||||||
| Address1: | 11141 PARKVIEW PLAZA DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668900 | ||||||||
| FaxNumber: | 2602668936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2021 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 28208897A | IN | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.