Healthcare Provider Details

I. General information

NPI: 1740379825
Provider Name (Legal Business Name): ELLEN ANN SAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21150 BISCAYNE BLVD SUITE 408
AVENTURA FL
33180-1226
US

IV. Provider business mailing address

11880 SW 40TH ST SUITE 304
MIAMI FL
33175-3584
US

V. Phone/Fax

Practice location:
  • Phone: 305-932-3252
  • Fax: 305-932-2798
Mailing address:
  • Phone: 305-223-8808
  • Fax: 305-223-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberPA9103517
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: