Provider Demographics
NPI:1568061281
Name:COBURN, SAMANTHA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:COBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:NICOLE
Other - Last Name:GASIOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3414 OLANDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1384
Mailing Address - Country:US
Mailing Address - Phone:301-774-0500
Mailing Address - Fax:301-774-7338
Practice Address - Street 1:3414 OLANDWOOD CT
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1384
Practice Address - Country:US
Practice Address - Phone:301-774-0500
Practice Address - Fax:301-774-7338
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0007752OtherMARYLAND BOARD OF PHYSICIANS