Provider Demographics
NPI:1245885482
Name:EZOLT, SAMANTHA K (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:K
Last Name:EZOLT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:K
Other - Last Name:ENGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:13 WESTERN MARYLAND PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6474
Mailing Address - Country:US
Mailing Address - Phone:301-665-4575
Mailing Address - Fax:301-665-4576
Practice Address - Street 1:13 WESTERN MARYLAND PKWY STE 104
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6474
Practice Address - Country:US
Practice Address - Phone:301-665-4575
Practice Address - Fax:301-665-4576
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant