Provider Demographics
NPI:1902326945
Name:DIEHL, SAMANTHA L (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:DIEHL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:L
Other - Last Name:LICHTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:703-396-5292
Mailing Address - Fax:
Practice Address - Street 1:8700 SUDLEY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-396-5292
Practice Address - Fax:703-396-5297
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11855363A00000X
363AM0700X
VA0110005843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical