Provider Demographics
NPI:1467972711
Name:CHILDERS, SAMANTHA (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-836-3900
Mailing Address - Fax:606-836-0205
Practice Address - Street 1:2420 ARGILLITE RD STE B
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1972
Practice Address - Country:US
Practice Address - Phone:606-836-3900
Practice Address - Fax:606-836-0205
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC618363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program