Healthcare Provider Details

I. General information

NPI: 1164813044
Provider Name (Legal Business Name): SAMANTHA RAE MEABON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA RAE RYAN PA-C

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W 27TH ST
ASHTABULA OH
44004-4975
US

IV. Provider business mailing address

416 W 27TH ST
ASHTABULA OH
44004-4975
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-5427
  • Fax:
Mailing address:
  • Phone: 440-997-5427
  • Fax: 440-997-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004298RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: