Healthcare Provider Details

I. General information

NPI: 1679954747
Provider Name (Legal Business Name): SAMANTHA PAYSENO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

IV. Provider business mailing address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-5200
  • Fax:
Mailing address:
  • Phone: 559-256-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA52554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: