Provider Demographics
NPI:1043863285
Name:PUSHCHAK, SAMANTHA JO (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:PUSHCHAK
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 1:850 E HARVARD AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5076
Mailing Address - Country:US
Mailing Address - Phone:303-306-4321
Mailing Address - Fax:
Practice Address - Street 1:850 E HARVARD AVE STE 305
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5076
Practice Address - Country:US
Practice Address - Phone:303-306-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005852207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine