Provider Demographics
NPI:1326370545
Name:FENDERSON, SAMUEL
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:FENDERSON
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 1:925 MAIN ST # 300-07
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3098
Mailing Address - Country:US
Mailing Address - Phone:678-799-2498
Mailing Address - Fax:
Practice Address - Street 1:925 MAIN ST # 300-07
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3098
Practice Address - Country:US
Practice Address - Phone:678-799-2498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty