Provider Demographics
NPI:1053806588
Name:STERN, SAMANTHA TALLIA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TALLIA
Last Name:STERN
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 1:501 PARK RIDGE CT APT R
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5606
Mailing Address - Country:US
Mailing Address - Phone:561-251-6936
Mailing Address - Fax:
Practice Address - Street 1:4208 EVERGREEN LN STE 213
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3254
Practice Address - Country:US
Practice Address - Phone:703-642-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-007502363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant