Provider Demographics
NPI:1285342188
Name:ANDERSON, SAMUEL JUSTIN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JUSTIN
Last Name:ANDERSON
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 1:239 SUGAR RUN RD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:WV
Mailing Address - Zip Code:26581-7709
Mailing Address - Country:US
Mailing Address - Phone:304-775-2666
Mailing Address - Fax:
Practice Address - Street 1:239 SUGAR RUN RD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:WV
Practice Address - Zip Code:26581-7709
Practice Address - Country:US
Practice Address - Phone:304-775-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1821206228Medicaid
WV1356607394Medicaid