Healthcare Provider Details

I. General information

NPI: 1932945185
Provider Name (Legal Business Name): SAMANTHA HURTADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 FRANKLIN AVE STE 211
GARDEN CITY NY
11530-5815
US

IV. Provider business mailing address

30 HARBOR CIR
CENTERPORT NY
11721-1608
US

V. Phone/Fax

Practice location:
  • Phone: 888-359-1833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032288
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: