Provider Demographics
NPI:1316353121
Name:NUCKOLS, SAMANTHA YATES (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:YATES
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SAMANTHA
Other - Middle Name:PAIGE
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 JAMESON WAY
Mailing Address - Street 2:
Mailing Address - City:SEVEN FIELDS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-4325
Mailing Address - Country:US
Mailing Address - Phone:757-406-9172
Mailing Address - Fax:
Practice Address - Street 1:11445 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7108
Practice Address - Country:US
Practice Address - Phone:314-428-9543
Practice Address - Fax:314-428-9542
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004588363A00000X
363A00000X
MO2017044296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant