Healthcare Provider Details

I. General information

NPI: 1629746482
Provider Name (Legal Business Name): RENEE ALI-SAMHOUL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 09/19/2021
Certification Date: 09/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 UNIVERSITY BLVD APT 206
JUPITER FL
33458-3063
US

IV. Provider business mailing address

819 UNIVERSITY BLVD
JUPITER FL
33458-3061
US

V. Phone/Fax

Practice location:
  • Phone: 954-778-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: