Healthcare Provider Details

I. General information

NPI: 1730699109
Provider Name (Legal Business Name): SAMANTHA KILIA TROUT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA K BLUEFARB PA-C

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

3131 NEWMARK DR STE 220
MIAMISBURG OH
45342-5400
US

V. Phone/Fax

Practice location:
  • Phone: 808-294-9379
  • Fax:
Mailing address:
  • Phone: 937-436-4658
  • Fax: 937-436-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005278RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number50.005278RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: