Provider Demographics
NPI:1649001082
Name:FAIRCHILD, SAMANTHA (PA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FAIRCHILD
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 1:3379 CROMPOND RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-3605
Mailing Address - Country:US
Mailing Address - Phone:914-930-5550
Mailing Address - Fax:914-930-5551
Practice Address - Street 1:3379 CROMPOND RD
Practice Address - Street 2:
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-3605
Practice Address - Country:US
Practice Address - Phone:914-930-5550
Practice Address - Fax:914-930-5551
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY129974OtherPROVISIONAL LICENSE