Provider Demographics
NPI:1821224858
Name:LUPTON, SAMANTHA JOELLE (AA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOELLE
Last Name:LUPTON
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:985-264-6438
Mailing Address - Fax:
Practice Address - Street 1:2308 WESVILL CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2949
Practice Address - Country:US
Practice Address - Phone:919-781-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030827367H00000X
NC200000010367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant