Provider Demographics
NPI:1447768031
Name:MCCAULEY, SAMANTHA ANNE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNE
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-952-2111
Mailing Address - Fax:423-282-1657
Practice Address - Street 1:2686 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1817
Practice Address - Country:US
Practice Address - Phone:423-844-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TN6247363A00000X
VA0110010426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer