Healthcare Provider Details

I. General information

NPI: 1467270009
Provider Name (Legal Business Name): SAMUEL PERENICH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 AIRPORT RD STE 100
HAZLE TOWNSHIP PA
18202-3379
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-7546
  • Fax: 570-455-7547
Mailing address:
  • Phone: 570-454-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119155
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: