Provider Demographics
NPI:1689627606
Name:SAMSON, DIANE K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:K
Last Name:SAMSON
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 1:13966 REDWOOD ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4135
Mailing Address - Country:US
Mailing Address - Phone:630-334-0968
Mailing Address - Fax:
Practice Address - Street 1:600 W 98TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4773
Practice Address - Country:US
Practice Address - Phone:952-885-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001315363A00000X
MN13040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant