Provider Demographics
NPI:1366984775
Name:PENNEPACKER, SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PENNEPACKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34990
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0627
Mailing Address - Country:US
Mailing Address - Phone:610-359-5672
Mailing Address - Fax:
Practice Address - Street 1:2004 SPROUL RD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3511
Practice Address - Country:US
Practice Address - Phone:610-359-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058738363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical