Provider Demographics
NPI:1740653294
Name:KOONTZ, SAMANTHA D (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:D
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:D
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:610 SOLAREX CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4599
Practice Address - Country:US
Practice Address - Phone:301-694-3111
Practice Address - Fax:301-694-8626
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005971363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580505Medicaid
MD926580503Medicaid
MD451LMedicare PIN
MD926580505Medicaid