Provider Demographics
NPI:1851957229
Name:LIEDERBACH, SAMANTHA MASON (PA)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MASON
Last Name:LIEDERBACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:MASON
Other - Last Name:SAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-5104
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-11
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024118363A00000X
NH1772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant