Provider Demographics
NPI:1154181022
Name:LWANYAGA, SAMUEL (AGPCNP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:LWANYAGA
Suffix:
Gender:M
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10211 WATERBURY CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-6143
Mailing Address - Country:US
Mailing Address - Phone:157-505-2853
Mailing Address - Fax:
Practice Address - Street 1:7501 HERITAGE VILLAGE PLZ
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3078
Practice Address - Country:US
Practice Address - Phone:157-150-5285
Practice Address - Fax:571-248-6455
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024189728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner