Healthcare Provider Details

I. General information

NPI: 1578039632
Provider Name (Legal Business Name): SAMUEL QUINCY GAINES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8459 COLERAIN AVE
CINCINNATI OH
45239-3938
US

IV. Provider business mailing address

8459 COLERAIN AVE
CINCINNATI OH
45239-3938
US

V. Phone/Fax

Practice location:
  • Phone: 513-815-3851
  • Fax: 859-572-2326
Mailing address:
  • Phone: 513-815-3851
  • Fax: 513-834-8944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: