Provider Demographics
NPI:1790371250
Name:GLEASON, SAMANTHA MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MAE
Last Name:GLEASON
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 1:353 HAWTHORNE LN NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3259
Mailing Address - Country:US
Mailing Address - Phone:321-795-5625
Mailing Address - Fax:
Practice Address - Street 1:14110 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3233
Practice Address - Country:US
Practice Address - Phone:722-202-2265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant