Provider Demographics
NPI:1568816882
Name:STEVENS, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 CAMINO DE SALUD
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3782
Mailing Address - Country:US
Mailing Address - Phone:505-272-1754
Mailing Address - Fax:505-925-4594
Practice Address - Street 1:1823 CAMINO DE SALUD
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3782
Practice Address - Country:US
Practice Address - Phone:505-272-1754
Practice Address - Fax:505-925-4594
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004612363A00000X
NMPA2024-0024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant