Provider Demographics
NPI:1083859482
Name:WENNERBERG, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WENNERBERG
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:PO BOX 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-620-4918
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:234 CROOKED CREEK PKWY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8505
Practice Address - Country:US
Practice Address - Phone:203-432-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-14
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001005699363AM0700X
CT2183367A00000X
NC0010-05699363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife