Provider Demographics
NPI:1770213308
Name:GOLD, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 KENILWORTH AVE FRNT
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4474
Mailing Address - Country:US
Mailing Address - Phone:216-570-7410
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0031541363LC0200X
OHRN.452641163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Single Specialty