Healthcare Provider Details

I. General information

NPI: 1023516754
Provider Name (Legal Business Name): SAMANTHA WALSH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SPARKS DR
FOREST CITY NC
28043-9021
US

IV. Provider business mailing address

112 SPARKS DR
FOREST CITY NC
28043-9021
US

V. Phone/Fax

Practice location:
  • Phone: 704-675-7279
  • Fax: 704-675-7279
Mailing address:
  • Phone: 828-351-6000
  • Fax: 828-287-7436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4500
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07920
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: