Provider Demographics
NPI:1083124432
Name:POND, SAMUEL (PA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:POND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16725 459TH AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-8718
Mailing Address - Country:US
Mailing Address - Phone:605-520-4777
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD STE 510
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8726
Practice Address - Country:US
Practice Address - Phone:314-251-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2025-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MO363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer