Provider Demographics
NPI:1093415705
Name:MEDER, SAMANTHA ASHLEY (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ASHLEY
Last Name:MEDER
Suffix:
Gender:F
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 1:1700 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4803
Mailing Address - Country:US
Mailing Address - Phone:772-461-4000
Mailing Address - Fax:
Practice Address - Street 1:1700 S 23RD ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4803
Practice Address - Country:US
Practice Address - Phone:772-461-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9116866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant