Provider Demographics
NPI:1417328311
Name:COLOSI, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:COLOSI
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 1:1500 WALNUT ST STE 1240
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3524
Mailing Address - Country:US
Mailing Address - Phone:267-687-4437
Mailing Address - Fax:
Practice Address - Street 1:1500 WALNUT ST STE 1240
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3524
Practice Address - Country:US
Practice Address - Phone:267-687-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-18
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003613363A00000X
NJ25MP00377900363A00000X
PAMA057786363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant