Provider Demographics
NPI:1104606961
Name:DURAN, SAM (PHD CLINICAL STUDENT)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:DURAN
Suffix:
Gender:M
Credentials:PHD CLINICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 W ASHLAN AVE APT 241
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-1918
Mailing Address - Country:US
Mailing Address - Phone:559-558-7961
Mailing Address - Fax:
Practice Address - Street 1:4946 E YALE AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1571
Practice Address - Country:US
Practice Address - Phone:559-458-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8405390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program