Provider Demographics
NPI:1124169982
Name:MEJIA, SAMUEL FERNANDO
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:FERNANDO
Last Name:MEJIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 IRELAND CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-1637
Mailing Address - Country:US
Mailing Address - Phone:910-353-1518
Mailing Address - Fax:
Practice Address - Street 1:703 IRELAND CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-1637
Practice Address - Country:US
Practice Address - Phone:910-353-1518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Not Answered3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301325BMedicaid