Provider Demographics
NPI:1871288753
Name:LO, SAMANTHA WEN-SHIN (MBBS)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:WEN-SHIN
Last Name:LO
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 JACKSON AVENUE
Mailing Address - Street 2:APT 15M
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:808-724-8971
Mailing Address - Fax:
Practice Address - Street 1:79-01 BROADWAY
Practice Address - Street 2:
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-334-3437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program