Healthcare Provider Details

I. General information

NPI: 1255825147
Provider Name (Legal Business Name): SAMANTHA JO BRAZEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219
US

IV. Provider business mailing address

4318 28TH ST
CINCINNATI OH
45209-1606
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-1000
  • Fax:
Mailing address:
  • Phone: 812-614-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005582RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: