NPIMap

Individual provider Active NPI

Disney Kulachati Samutsakorn, PA-C

  • Physician Assistant
  • Fort Bragg, NC
National Provider Identifier
1255875571
Registry record updated Aug 24, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0010-14417 Issued in NC
Practice address
2817 Rock Merritt Ave
Fort Bragg, NC 28310-4504
Phone
(910) 907-8922
Fax
(910) 907-6069
NPI assigned
Dec 5, 2016
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Aug 24, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 0010-14417 NC Primary

Addresses

Primary practice location

2817 Rock Merritt Ave
Fort Bragg, NC 28310-4504

Mailing address

PO Box 40908
Fayetteville, NC 28309-0908
Phone (910) 615-6949

Other practice location 1

6387 Ramsey St Unit 100
Fayetteville, NC 28311-9442
Phone (910) 615-7070

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250107003566 NC Practitioner - Physician Assistant 6507234283 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

150 Robeson St
Fayetteville, NC 28301-5570
Phone (910) 615-1059

6387 Ramsey St
Unit 100
Fayetteville, NC 28311-9442
Phone (910) 615-3879

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
1138817NCMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Cumberland County Hospital System Inc CurrentSince Nov 17, 2025 Accepting new patients
CFV Express Care Billing Services LLC CurrentSince Nov 17, 2025 Accepting new patients
Cumberland County Hospital System Inc CurrentSince Nov 17, 2025 Accepting new patients
Cumberland County Hospital System Inc Past Accepting new patients
Bladen Medical Associates PastSince Apr 6, 2025 Accepting new patients

Locations

150 Robeson St
Fayetteville, NC 28301
Phone (910) 609-1000

1638 Owen Dr
Fayetteville, NC 28304
Phone (910) 609-5610

6387 Ramsey St
Unit 100
Fayetteville, NC 28311
Phone (910) 615-3879

Interoperability endpoints

  • Direct secure messaging: dsamutsakorn140448@capefearvalley.direct-ci.com

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 15

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1480896000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1787529600000",
    "number": "1255875571",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 40908",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283090908",
            "telephone_number": "910-615-6949",
            "fax_number": "910-615-9761"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2817 ROCK MERRITT AVE",
            "city": "FORT BRAGG",
            "state": "NC",
            "postal_code": "283104504",
            "telephone_number": "910-907-8922",
            "fax_number": "910-907-6069"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "6387 Ramsey St Unit 100",
            "address_purpose": "LOCATION",
            "city": "Fayetteville",
            "state": "NC",
            "postal_code": "283119442",
            "country_code": "US",
            "telephone_number": "910-615-7070",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SAMUTSAKORN",
        "first_name": "DISNEY",
        "middle_name": "KULACHATI",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-12-05",
        "last_updated": "2026-08-24",
        "certification_date": "2026-08-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-14417",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Bragg, NC

Sources for this page

Verify at the official NPI Registry.