Provider Demographics
NPI:1578962056
Name:GRANEY, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRANEY
Suffix:
Gender:F
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 1:2 TABOR ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1342
Mailing Address - Country:US
Mailing Address - Phone:732-829-6726
Mailing Address - Fax:
Practice Address - Street 1:2 TABOR ST
Practice Address - Street 2:
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739-1342
Practice Address - Country:US
Practice Address - Phone:732-829-6726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant