Provider Demographics
NPI:1568836369
Name:EMANUELSON, SAMANTHA J (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:EMANUELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:J
Other - Last Name:TARMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-4600
Mailing Address - Fax:414-808-2934
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-4600
Practice Address - Fax:414-808-2934
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3689-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568836369Medicaid