MEDICARE: SAMANTHA MARIE WAHNER

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	225200000X	Physical Therapy Assistant	4350-19	WI

General Provider Information

NPI Number	:	1497682587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA MARIE WAHNER

Provider Business Mailing Address
First Line	:	6915 67TH ST UNIT 104
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-1477
Country	:	US
Telephone Number	:	414-430-0308
Fax Number	:

Provider Business Practice Location Address
First Line	:	6308 8TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5031
Country	:	US
Telephone Number	:	126-265-6390
Fax Number	:

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

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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