Provider Demographics
NPI:1790937217
Name:AMATO-ROTKOWITZ, SAMANTHA PARK (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:PARK
Last Name:AMATO-ROTKOWITZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:PARK
Other - Last Name:AMATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1331 E WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3808
Mailing Address - Country:US
Mailing Address - Phone:215-537-7065
Mailing Address - Fax:215-537-7861
Practice Address - Street 1:1331 E WYOMING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3808
Practice Address - Country:US
Practice Address - Phone:215-537-7065
Practice Address - Fax:215-537-7861
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00207500363A00000X
PAMD063556L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00207500OtherMEDICAL LICENSE
PAMD063556LOtherMEDICAL LICENSE