Provider Demographics
NPI:1548779580
Name:FAWAZ, SAMAR
Entity Type:Individual
Prefix:
First Name:SAMAR
Middle Name:
Last Name:FAWAZ
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 1:2065 HIGHWAY A1A APT 1403
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-1811
Mailing Address - Country:US
Mailing Address - Phone:313-574-2965
Mailing Address - Fax:321-603-3560
Practice Address - Street 1:175 VILLA NUEVA AVE NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2595
Practice Address - Country:US
Practice Address - Phone:313-574-2965
Practice Address - Fax:321-603-3560
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008292363A00000X
FLPA9111341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP02091188OtherRRMEDICARE PTAN
FL101048700Medicaid
FLJL436ZOtherMEDICARE PTAN