Provider Demographics
NPI:1578527057
Name:SAMSOE, HENRY N (PA-C)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:N
Last Name:SAMSOE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-734-9122
Mailing Address - Fax:386-736-4348
Practice Address - Street 1:740 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3282
Practice Address - Country:US
Practice Address - Phone:386-734-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292882500Medicaid
FLU4281AMedicare ID - Type UnspecifiedMEDICARE NO
FL292882500Medicaid