Provider Demographics
NPI:1982023412
Name:NICHOLS, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:NICHOLS
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 1:9000 ROCKVILLE PIKE BLDG 10
Mailing Address - Street 2:RM 12-C-101
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20892-0001
Mailing Address - Country:US
Mailing Address - Phone:250-858-3219
Mailing Address - Fax:
Practice Address - Street 1:9000 ROCKVILLE PIKE BLDG 10
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-4009
Practice Address - Country:US
Practice Address - Phone:240-858-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-11
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338140201Medicaid
TX347122YKQHMedicare PIN