Provider Demographics
NPI:1093959611
Name:REYNOLDS, SAMANTHA JANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JANE
Last Name:REYNOLDS
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 1:52 W SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186
Mailing Address - Country:US
Mailing Address - Phone:540-347-9220
Mailing Address - Fax:540-347-9298
Practice Address - Street 1:1100 SUNSET LANE 1211-A
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701
Practice Address - Country:US
Practice Address - Phone:540-825-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000733U96Medicare UPIN