Provider Demographics
NPI:1295211159
Name:SAMOYLOVA, POLINA MOISEYEVNA (NP)
Entity Type:Individual
Prefix:MS
First Name:POLINA
Middle Name:MOISEYEVNA
Last Name:SAMOYLOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MAGEE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5555
Mailing Address - Country:US
Mailing Address - Phone:520-638-5553
Mailing Address - Fax:520-638-5543
Practice Address - Street 1:400 W MAGEE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6438
Practice Address - Country:US
Practice Address - Phone:520-638-5553
Practice Address - Fax:520-638-5543
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11404363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP11404OtherARIZONA STATE BOARD OF NURSING
AZF06182317OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD
AZ1295211159Medicaid