Healthcare Provider Details

I. General information

NPI: 1154108256
Provider Name (Legal Business Name): SAMANTHA TANNY HEUER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BRECKENRIDGE LN STE 400
LOUISVILLE KY
40220-1402
US

IV. Provider business mailing address

642 BAXTER AVE APT 401
LOUISVILLE KY
40204-2270
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-1111
  • Fax:
Mailing address:
  • Phone: 606-465-8715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC030
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: