Provider Demographics
NPI:1245854165
Name:DASTRUP, SAMANTHA (AGNP-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DASTRUP
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4688 W TANGERINE RD APT 2105
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85658-4866
Mailing Address - Country:US
Mailing Address - Phone:719-342-5809
Mailing Address - Fax:
Practice Address - Street 1:5350 E ERICKSON DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2822
Practice Address - Country:US
Practice Address - Phone:520-733-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242012363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology