Provider Demographics
NPI:1578176475
Name:BALTAZAR, SAMANTHA (PA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 E CAROLINE ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3731
Mailing Address - Country:US
Mailing Address - Phone:909-558-3636
Mailing Address - Fax:
Practice Address - Street 1:197 E CAROLINE ST STE 1400
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3731
Practice Address - Country:US
Practice Address - Phone:099-558-3636
Practice Address - Fax:909-558-3754
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NVPA3107363AM0700X
CAPA58722363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant