Basic Information
| Provider Information | |||||||||
| NPI: | 1871242628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANADE | ||||||||
| FirstName: | SAMSON | ||||||||
| MiddleName: | O | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP STE 604 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608781 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 587 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314216510 | ||||||||
| FaxNumber: | 7314216515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2022 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 7502 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.