Provider Demographics
NPI:1093830291
Name:TANN, SAMANDRA (NP-C)
Entity type:Individual
Prefix:
First Name:SAMANDRA
Middle Name:
Last Name:TANN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 E WENDOVER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1207
Mailing Address - Country:US
Mailing Address - Phone:336-274-3241
Mailing Address - Fax:336-272-7134
Practice Address - Street 1:2645 MERIDIAN PKWY STE 323
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-4232
Practice Address - Country:US
Practice Address - Phone:984-227-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171266363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2592864AMedicare PIN