MEDICARE: MRS. SAMANTHA J VAN GINNEKEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA 1294	NV
2	363A00000X	Physician Assistant	PA1294	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PA1294	OTHER	NV	STATE LICENSE

General Provider Information

NPI Number	:	1225315229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SAMANTHA J VAN GINNEKEN PA-C

Provider Business Mailing Address
First Line	:	6355 S BUFFALO DR FL 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2133
Country	:	US
Telephone Number	:	702-216-3346
Fax Number	:	702-671-6883

Provider Business Practice Location Address
First Line	:	5320 S RAINBOW BLVD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-1807
Country	:	US
Telephone Number	:	702-944-7105
Fax Number	:	702-944-7110

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2011
Last Update Date	:	10/20/2022

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Directions to “ MRS. SAMANTHA J VAN GINNEKEN PA-C” Practice Location

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