Provider Demographics
NPI:1528420429
Name:PLASTIC SURGERY ASSOCIATES OF TIDEWATER
Entity type:Organization
Organization Name:PLASTIC SURGERY ASSOCIATES OF TIDEWATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PERSSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:540-493-7759
Mailing Address - Street 1:5818 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3315
Mailing Address - Country:US
Mailing Address - Phone:757-673-6000
Mailing Address - Fax:757-673-6007
Practice Address - Street 1:5818 HARBOUR VIEW BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-673-6000
Practice Address - Fax:757-673-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173410363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty