Provider Demographics
NPI:1164899530
Name:MASTERSON, SAMANTHA
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 PLEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12594-1420
Mailing Address - Country:US
Mailing Address - Phone:845-797-1239
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:845-797-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY963874151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist