Provider Demographics
NPI:1053176198
Name:POLLOCK, SAMANTHA DENISE (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DENISE
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 VERNON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4129
Mailing Address - Country:US
Mailing Address - Phone:706-803-7510
Mailing Address - Fax:
Practice Address - Street 1:1602 VERNON RD STE 300
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4129
Practice Address - Country:US
Practice Address - Phone:706-803-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12445363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical