Healthcare Provider Details

I. General information

NPI: 1689438087
Provider Name (Legal Business Name): SAMANTHA LYNN PAVOLKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3356 BIRNEY PLZ
MOOSIC PA
18507-1560
US

IV. Provider business mailing address

167 E 7TH ST
WYOMING PA
18644-2042
US

V. Phone/Fax

Practice location:
  • Phone: 570-347-7790
  • Fax:
Mailing address:
  • Phone: 484-515-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT032106
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT032106
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: