Provider Demographics
NPI:1962876516
Name:GREENE, SAMANTHA M (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:GREENE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:M
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:41 JACKSON LOOP
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-8819
Mailing Address - Country:US
Mailing Address - Phone:757-402-6166
Mailing Address - Fax:
Practice Address - Street 1:11819 MAUMELLE BLVD
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72113-6567
Practice Address - Country:US
Practice Address - Phone:501-771-9355
Practice Address - Fax:501-771-9360
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA-1293363A00000X
VA0110005133363A00000X
UT12196775-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2086587Medicaid