Provider Demographics
NPI:1497123228
Name:HARDWICKE, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HARDWICKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 59TH ST W
Mailing Address - Street 2:2200
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4616
Mailing Address - Country:US
Mailing Address - Phone:941-794-5621
Mailing Address - Fax:
Practice Address - Street 1:2010 59TH ST W
Practice Address - Street 2:2200
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4616
Practice Address - Country:US
Practice Address - Phone:941-794-5621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9108919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant