Provider Demographics
NPI:1437875499
Name:MCINTIRE, SAMANTHA J (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:MCINTIRE
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 1:277 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-2810
Mailing Address - Country:US
Mailing Address - Phone:865-262-9294
Mailing Address - Fax:
Practice Address - Street 1:1668 LILLIAN CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5419
Practice Address - Country:US
Practice Address - Phone:931-698-0489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant