Provider Demographics
NPI:1861063307
Name:FERRELL, SAM (SCT(ASCP), MT(AMT))
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:FERRELL
Suffix:
Gender:M
Credentials:SCT(ASCP), MT(AMT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 SCOTT CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2460
Mailing Address - Country:US
Mailing Address - Phone:925-503-9562
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1563
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
676246QC2700X
2736023291U00000X
CA02039975246QC2700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QC2700XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyCytotechnology
No291U00000XLaboratoriesClinical Medical Laboratory