=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104151570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA JO STEELMAN PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2009
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 SUNSET ST
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-772-5578
-----------------------------------------------------
Fax | 970-482-0679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 ARCHES CT
-----------------------------------------------------
City | BERTHOUD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80513-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-381-2803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2835
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------