Basic Information
| Provider Information | |||||||||
| NPI: | 1184638629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMUELS | ||||||||
| FirstName: | NATHAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019153012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019153012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP258431 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | NP9661 | 01 | MA | BS | OTHER |