Provider Demographics
NPI:1730514993
Name:SAMPSON, TOMMY WAYNE (CRNA)
Entity type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:WAYNE
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N NAPPANEE ST
Mailing Address - Street 2:SUITE 11B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1503
Mailing Address - Country:US
Mailing Address - Phone:574-522-9922
Mailing Address - Fax:574-522-9926
Practice Address - Street 1:500 N NAPPANEE ST
Practice Address - Street 2:SUITE 11B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1503
Practice Address - Country:US
Practice Address - Phone:574-522-9922
Practice Address - Fax:574-522-9926
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101222367500000X
MO2016033441367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered