Provider Demographics
NPI:1598399743
Name:VAILLANCOURT, SAMANTHA PANDICK (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PANDICK
Last Name:VAILLANCOURT
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 1:1111 LOTUS LILLY DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-2558
Mailing Address - Country:US
Mailing Address - Phone:919-280-0622
Mailing Address - Fax:
Practice Address - Street 1:1236 HUFFMAN MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-227-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant