Provider Demographics
NPI:1598309510
Name:DESSOURCES, SAMANTHA JEAN-GUILLAUME (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN-GUILLAUME
Last Name:DESSOURCES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:JEAN-GUILLAUME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4954 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762
Mailing Address - Country:US
Mailing Address - Phone:516-308-7255
Mailing Address - Fax:
Practice Address - Street 1:4954 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762
Practice Address - Country:US
Practice Address - Phone:516-308-7255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025045-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program