Provider Demographics
NPI:1013537893
Name:SYRETT, SAMANTHA L (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:SYRETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:BRUETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3844 S LINDBERGH BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1387
Mailing Address - Country:US
Mailing Address - Phone:314-525-0420
Mailing Address - Fax:
Practice Address - Street 1:3844 S LINDBERGH BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1387
Practice Address - Country:US
Practice Address - Phone:314-525-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021002419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant