Healthcare Provider Details

I. General information

NPI: 1205652724
Provider Name (Legal Business Name): SAMANTHA WELT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2024
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11948 BALM RIVERVIEW RD
RIVERVIEW FL
33569-6601
US

IV. Provider business mailing address

11948 BALM RIVERVIEW RD
RIVERVIEW FL
33569-6601
US

V. Phone/Fax

Practice location:
  • Phone: 813-656-9553
  • Fax:
Mailing address:
  • Phone: 813-656-9553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9564
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: