Provider Demographics
NPI:1740379825
Name:SAM, ELLEN ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:ANN
Last Name:SAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11880 SW 40TH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-223-8808
Mailing Address - Fax:305-223-8974
Practice Address - Street 1:21150 BISCAYNE BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1226
Practice Address - Country:US
Practice Address - Phone:305-932-3252
Practice Address - Fax:305-932-2798
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103517207K00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL007ZOtherMEDICARE
FLAL007YOtherMEDICARE
FL292823000Medicaid