Provider Demographics
NPI:1043692239
Name:WOLFF, SAMANTHA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:WOLFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:VICKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:MCW-DIVISION OF COLORECTAL SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5783
Mailing Address - Fax:414-454-0152
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:MCW-DIVISION OF COLORECTAL SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5783
Practice Address - Fax:414-454-0152
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3562-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043692239Medicaid