Provider Demographics
NPI:1376597492
Name:SAMUELS, MOLLY A (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:A
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 WILLIAMSON RD
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2850
Mailing Address - Country:US
Mailing Address - Phone:814-807-1155
Mailing Address - Fax:
Practice Address - Street 1:16792 CONNEAUT LAKE ROAD
Practice Address - Street 2:ONCOLOGY WELLNESS INSTITUTE, MMC
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2850
Practice Address - Country:US
Practice Address - Phone:814-373-2335
Practice Address - Fax:814-373-2338
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011706363A00000X, 363AM0700X, 363AS0400X
PAMA052541363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071842Medicare ID - Type Unspecified
PA101819F73Medicare ID - Type Unspecified