Provider Demographics
NPI:1144381351
Name:SAMUELSON, PATRICIA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:LYNN
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 12TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-1929
Mailing Address - Country:US
Mailing Address - Phone:916-469-4690
Mailing Address - Fax:
Practice Address - Street 1:3415 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-3648
Practice Address - Country:US
Practice Address - Phone:916-737-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G556440Medicaid
CAE30294Medicare UPIN
CA00G556440Medicaid