Provider Demographics
NPI:1790073724
Name:LAGACE, SAMANTHA L (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:LAGACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SAMATHA
Other - Middle Name:L
Other - Last Name:ROCKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 9312
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-0312
Mailing Address - Country:US
Mailing Address - Phone:518-690-0177
Mailing Address - Fax:518-690-0169
Practice Address - Street 1:2508 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-9485
Practice Address - Country:US
Practice Address - Phone:518-690-0177
Practice Address - Fax:518-690-0169
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03406526Medicaid
NY03406526Medicaid