MEDICARE: SAMANTHA HICKEY

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	5601008454	MI

General Provider Information

NPI Number	:	1801308291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA HICKEY

Provider Business Mailing Address
First Line	:	5120 AUTUMN RIDGE CT
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	37935 W 12 MILE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-3035
Country	:	US
Telephone Number	:	248-987-4877
Fax Number	:

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

Provider Enumeration Date	:	10/25/2017
Last Update Date	:	01/17/2023

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