Provider Demographics
NPI:1417355819
Name:ETHRIDGE, SAMANTHA KAYE (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAYE
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:KAYE
Other - Last Name:GAMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:1800 GURLEY LN
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-4025
Practice Address - Country:US
Practice Address - Phone:254-313-6000
Practice Address - Fax:254-313-6099
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant