MEDICARE: SAMUEL QUINCY GAINES 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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1578039632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL QUINCY GAINES PA-C

Provider Business Mailing Address
First Line	:	8459 COLERAIN AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45239-3938
Country	:	US
Telephone Number	:	513-815-3851
Fax Number	:	513-834-8944

Provider Business Practice Location Address
First Line	:	8459 COLERAIN AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45239-3938
Country	:	US
Telephone Number	:	513-815-3851
Fax Number	:	859-572-2326

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

Provider Enumeration Date	:	10/16/2018
Last Update Date	:	06/07/2021

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