Provider Demographics
NPI:1982340105
Name:VAN TASSEL, SAMANTHA ANN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:VAN TASSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 AMARANTH PL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4101
Mailing Address - Country:US
Mailing Address - Phone:978-914-3471
Mailing Address - Fax:
Practice Address - Street 1:12 AMARANTH PL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4101
Practice Address - Country:US
Practice Address - Phone:978-914-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANA207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services