Provider Demographics
NPI:1801118765
Name:RODGERS, SAMANTHA (PA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:HUME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:107 W HARGETT ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1700
Mailing Address - Country:US
Mailing Address - Phone:904-900-5452
Mailing Address - Fax:904-425-6356
Practice Address - Street 1:5214 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-4067
Practice Address - Country:US
Practice Address - Phone:910-782-3284
Practice Address - Fax:910-796-8379
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054195363AM0700X
NJ25MP00385200363AS0400X
NC308938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA178482KAGMedicare PIN