Provider Demographics
NPI:1144606351
Name:BLACK, SAMANTHA K (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:K
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 UNION RD STE 218
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4251
Mailing Address - Country:US
Mailing Address - Phone:716-206-1503
Mailing Address - Fax:716-651-9945
Practice Address - Street 1:825 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-634-3243
Practice Address - Fax:716-634-6056
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001929A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical