Healthcare Provider Details

I. General information

NPI: 1508340696
Provider Name (Legal Business Name): SAMANTHA HASTIE LECONEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 AUBURN AVE
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

6480 HARRISON AVE STE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 513-463-2500
  • Fax: 513-463-2510
Mailing address:
  • Phone: 513-354-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2496
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2496
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.005713RX
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.005713RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: