Healthcare Provider Details

I. General information

NPI: 1851024145
Provider Name (Legal Business Name): SAMANTHA FEDOROWICZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 FISH HATCHERY RD
MADISON WI
53715-1909
US

IV. Provider business mailing address

1805 BELD ST
MADISON WI
53713-1309
US

V. Phone/Fax

Practice location:
  • Phone: 608-252-8000
  • Fax: 608-288-6490
Mailing address:
  • Phone: 608-807-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8010-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: