Healthcare Provider Details

I. General information

NPI: 1932617651
Provider Name (Legal Business Name): SAMANTHA NIKLAUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12601 NARCOOSSEE RD STE 209
ORLANDO FL
32832-7144
US

IV. Provider business mailing address

11945 SAN JOSE BLVD
JACKSONVILLE FL
32223-1613
US

V. Phone/Fax

Practice location:
  • Phone: 407-605-3777
  • Fax: 321-473-4839
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-396-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9113368
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: