MEDICARE: SAMANTHA CONSIDINE PEZON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		MN

General Provider Information

NPI Number	:	1114620721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA CONSIDINE PEZON MD

Provider Business Mailing Address
First Line	:	PEDS EDUCATION OFFICE M136, 1ST FLOOR, EAST BUILDING
Second Line	:	2540 RIVERSIDE AVE
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454
Country	:	US
Telephone Number	:	612-624-4477
Fax Number	:

Provider Business Practice Location Address
First Line	:	PEDS EDUCATION OFFICE M136, 1ST FLOOR, EAST BUILDING
Second Line	:	2540 RIVERSIDE AVE
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454
Country	:	US
Telephone Number	:	612-624-4477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2023
Last Update Date	:	06/17/2026

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