Healthcare Provider Details

I. General information

NPI: 1215666565
Provider Name (Legal Business Name): SAMUEL RANNEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

3689 BALBOA CT
LAS CRUCES NM
88012-8042
US

IV. Provider business mailing address

3689 BALBOA CT
LAS CRUCES NM
88012-8042
US

V. Phone/Fax

Practice location:
  • Phone: 847-471-0644
  • Fax:
Mailing address:
  • Phone: 847-471-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9115845
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: