Provider Demographics
NPI:1124532932
Name:SAMARA, MELISSA ADRIANA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:ADRIANA
Last Name:SAMARA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ADRIANA
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:475-210-5604
Mailing Address - Fax:465-210-6368
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:475-210-5604
Practice Address - Fax:465-210-6368
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant