Healthcare Provider Details

I. General information

NPI: 1972544997
Provider Name (Legal Business Name): SAMANTHA S GREENE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4945 SW 49TH PL
OCALA FL
34474-9673
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 352-237-9430
  • Fax: 352-237-9698
Mailing address:
  • Phone: 239-432-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101566
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: