Provider Demographics
NPI:1891344081
Name:ZOLTAK, SAMANTHA (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ZOLTAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 ALLEN CT
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9782
Mailing Address - Country:US
Mailing Address - Phone:803-510-0007
Mailing Address - Fax:803-510-0144
Practice Address - Street 1:140 ALLEN CT
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29860-9782
Practice Address - Country:US
Practice Address - Phone:803-510-0007
Practice Address - Fax:803-510-0144
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant