Healthcare Provider Details

I. General information

NPI: 1659036119
Provider Name (Legal Business Name): SAMANTHA MARIE WINZENREAD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 05/02/2023
Certification Date: 01/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FIVE FORK PLAZA CT UNIT A
SIMPSONVILLE SC
29681-5460
US

IV. Provider business mailing address

11 FIVE FORK PLAZA CT STE A
SIMPSONVILLE SC
29681-5460
US

V. Phone/Fax

Practice location:
  • Phone: 864-627-0444
  • Fax: 864-627-0555
Mailing address:
  • Phone: 864-627-0444
  • Fax: 864-627-0555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMPA.4188
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: