Provider Demographics
NPI:1790004596
Name:TICCHI-JUNKINS, SAMANTHA J (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:TICCHI-JUNKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 HUGHES DR
Mailing Address - Street 2:220
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3856
Mailing Address - Country:US
Mailing Address - Phone:419-291-5150
Mailing Address - Fax:419-479-6173
Practice Address - Street 1:2109 HUGHES DR
Practice Address - Street 2:220
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3856
Practice Address - Country:US
Practice Address - Phone:419-291-5150
Practice Address - Fax:419-479-6173
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-003056363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074294Medicaid
OHPA877541Medicare PIN