Provider Demographics
NPI:1245636182
Name:SCHAMP, SAMANTHA MARIKO (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIKO
Last Name:SCHAMP
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 1:522 W CARSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2635
Mailing Address - Country:US
Mailing Address - Phone:310-320-3400
Mailing Address - Fax:424-781-8651
Practice Address - Street 1:522 W CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2635
Practice Address - Country:US
Practice Address - Phone:310-320-3400
Practice Address - Fax:424-781-8651
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant