Provider Demographics
NPI:1629444849
Name:MCKINNEY, SAMANTHA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RENEE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:784 HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:FRENCHBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40322-8123
Mailing Address - Country:US
Mailing Address - Phone:606-768-9190
Mailing Address - Fax:606-768-9180
Practice Address - Street 1:784 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:FRENCHBURG
Practice Address - State:KY
Practice Address - Zip Code:40322-8123
Practice Address - Country:US
Practice Address - Phone:606-768-9190
Practice Address - Fax:606-768-9180
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100378300Medicaid
KY7100378300Medicaid
KYK161811Medicare PIN
KYK161812Medicare PIN
KYK161813Medicare PIN