Provider Demographics
NPI:1043779697
Name:DIAZ, SAMANTHA RAQUEL (CNM)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAQUEL
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RAQUEL
Other - Last Name:GAUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 GRANDVIEW AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-1729
Mailing Address - Country:US
Mailing Address - Phone:717-988-9015
Mailing Address - Fax:
Practice Address - Street 1:225 GRANDVIEW AVE STE 302
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-1729
Practice Address - Country:US
Practice Address - Phone:717-988-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010519367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife