Basic Information
Provider Information | |||||||||
NPI: | 1366924789 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEGREGORIO | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, CRNA, DNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOFMANN | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 118 SES DRIVE | ||||||||
Address2: |   | ||||||||
City: | CLAYTON | ||||||||
State: | NC | ||||||||
PostalCode: | 27520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3159455606 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2460 CURTIS ELLIS DR | ||||||||
Address2: |   | ||||||||
City: | ROCKY MOUNT | ||||||||
State: | NC | ||||||||
PostalCode: | 27804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2529628000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2018 | ||||||||
LastUpdateDate: | 09/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 258637 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.