Provider Demographics
NPI:1861743999
Name:GATES, SAMANTHA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:GATES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:KOLASA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:704-335-8448
Practice Address - Street 1:225 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3109
Practice Address - Country:US
Practice Address - Phone:704-376-1605
Practice Address - Fax:704-335-8448
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04547363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant