Healthcare Provider Details

I. General information

NPI: 1306476759
Provider Name (Legal Business Name): SAMANTHA SUE SELLERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 03/13/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

2243 ROLLING PINES RD
CHIPLEY FL
32428
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-8341
  • Fax:
Mailing address:
  • Phone: 904-314-3891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA9115984
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0010-9729
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-9729
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9115984
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: