Provider Demographics
NPI:1649955485
Name:WILSON, SAMANTHA TERESA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TERESA
Last Name:WILSON
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 1:13 RICHARD ST
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-2819
Mailing Address - Country:US
Mailing Address - Phone:781-854-6776
Mailing Address - Fax:
Practice Address - Street 1:60 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6128
Practice Address - Country:US
Practice Address - Phone:617-525-6759
Practice Address - Fax:617-713-3050
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant