Provider Demographics
NPI:1104526573
Name:DUVALL, SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DUVALL
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:PO BOX 1533
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1533
Mailing Address - Country:US
Mailing Address - Phone:870-932-1820
Mailing Address - Fax:
Practice Address - Street 1:1010 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3503
Practice Address - Country:US
Practice Address - Phone:870-932-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-1158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA-1158OtherMEDICAL LICENSE NUMBER