Provider Demographics
NPI:1740991504
Name:GULLEDGE, SAMANTHA DARE (PA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DARE
Last Name:GULLEDGE
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:PO BOX 23329
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-3329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1099 MEDICAL CENTER DR
Practice Address - Street 2:SUITES 100 AND 201
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-251-9994
Practice Address - Fax:910-763-4666
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12847363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant