Provider Demographics
NPI:1417370685
Name:WILHELM, SAMANTHA (MS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:WILHELM
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:EASLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PA-C
Mailing Address - Street 1:4560 ADMIRALTY WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5424
Mailing Address - Country:US
Mailing Address - Phone:310-694-5255
Mailing Address - Fax:310-306-5555
Practice Address - Street 1:4560 ADMIRALTY WAY STE 105
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5424
Practice Address - Country:US
Practice Address - Phone:310-694-5255
Practice Address - Fax:310-306-5555
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant