Healthcare Provider Details

I. General information

NPI: 1912738097
Provider Name (Legal Business Name): SAMANTHA MANKUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CELEBRATION PL STE 305
CELEBRATION FL
34747-5436
US

IV. Provider business mailing address

410 CELEBRATION PL STE 305
CELEBRATION FL
34747-5436
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-4120
  • Fax: 407-303-4124
Mailing address:
  • Phone: 407-303-4120
  • Fax: 407-303-4124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9119677
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119677
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: