Provider Demographics
NPI:1275022618
Name:WLOCH, SAMANTHA ANNA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNA
Last Name:WLOCH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6143 BRIDLEFORD DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-3840
Mailing Address - Country:US
Mailing Address - Phone:813-956-4726
Mailing Address - Fax:
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:888-663-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111230363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical