MEDICARE: SAMANTHA STEVENS

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	363A00000X	Physician Assistant	PA.0004612	CO
2	363A00000X	Physician Assistant	PA2024-0024	NM

General Provider Information

NPI Number	:	1568816882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA STEVENS

Provider Business Mailing Address
First Line	:	1823 CAMINO DE SALUD
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-3782
Country	:	US
Telephone Number	:	505-272-1754
Fax Number	:	505-925-4594

Provider Business Practice Location Address
First Line	:	1823 CAMINO DE SALUD
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-3782
Country	:	US
Telephone Number	:	505-272-1754
Fax Number	:	505-925-4594

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

Provider Enumeration Date	:	04/22/2016
Last Update Date	:	07/22/2024

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Directions to “ SAMANTHA STEVENS ” Practice Location

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