MEDICARE: SAMANTHA ANN OLSENEVICH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	4829	CT
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1407474430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ANN OLSENEVICH PA-C

Provider Business Mailing Address
First Line	:	263 FARMINGTON AVE
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06030-8082
Country	:	US
Telephone Number	:	860-679-2792
Fax Number	:	860-679-1494

Provider Business Practice Location Address
First Line	:	263 FARMINGTON AVE
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06030-8085
Country	:	US
Telephone Number	:	860-679-2792
Fax Number	:	860-679-1494

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2020
Last Update Date	:	02/06/2026

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