Provider Demographics
NPI:1154742724
Name:PEARSON, SAMUEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:5801 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2536
Practice Address - Country:US
Practice Address - Phone:804-288-1380
Practice Address - Fax:804-288-1383
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154742724OtherMEDICAID QMB ONLY
VAC05954OtherMEDICARE GROUP PTAN
VAC05954OtherMEDICARE GROUP PTAN