Provider Demographics
NPI:1508017674
Name:SAMUELS, SANDRA LEIGH (PA-C)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LEIGH
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEIGH
Other - Last Name:POELKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 BELLA GROVE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 BELLA GROVE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3459
Practice Address - Country:US
Practice Address - Phone:864-603-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NVPA1903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12798087OtherCAQH