Healthcare Provider Details

I. General information

NPI: 1043863285
Provider Name (Legal Business Name): SAMANTHA JO PUSHCHAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SOUTHPARK DR
LITTLETON CO
80120-5654
US

IV. Provider business mailing address

1000 SOUTHPARK DR
LITTLETON CO
80120-5654
US

V. Phone/Fax

Practice location:
  • Phone: 303-744-1065
  • Fax: 303-733-1699
Mailing address:
  • Phone: 303-744-1065
  • Fax: 303-733-1699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPA.0005852
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberPA.0005852
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.5852
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: