Samuel Fenderson

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

Practice address

925 Main St # 300-07
Stone Mountain, GA 30083-3098

Phone

(678) 799-2498

NPI assigned

Feb 12, 2010

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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

{
    "created_epoch": "1265932800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1519862400000",
    "number": "1326370545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "925 MAIN ST # 300-07",
            "city": "STONE MOUNTAIN",
            "state": "GA",
            "postal_code": "300833098",
            "telephone_number": "678-799-2498"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "925 MAIN ST # 300-07",
            "city": "STONE MOUNTAIN",
            "state": "GA",
            "postal_code": "300833098",
            "telephone_number": "678-799-2498"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FENDERSON",
        "first_name": "SAMUEL",
        "name_prefix": "Mr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-02-12",
        "last_updated": "2018-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "246ZC0007X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Other, Surgical Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Surgical Physician Assistant in Stone Mountain, GA
• Providers in Stone Mountain, GA by specialty
• Surgical Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.