Provider Demographics
NPI:1508017674
Name:SAMUELS, SANDRA LEIGH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LEIGH
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEIGH
Other - Last Name:POELKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6255 SHARLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-2882
Mailing Address - Country:US
Mailing Address - Phone:775-432-6837
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:6255 SHARLANDS AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-2882
Practice Address - Country:US
Practice Address - Phone:775-432-6837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1903363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12798087OtherCAQH