Provider Demographics
NPI:1811547763
Name:BOGAN, SAMANTHA (NP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:BOGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CHESNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:92 HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3827
Mailing Address - Country:US
Mailing Address - Phone:917-780-6910
Mailing Address - Fax:
Practice Address - Street 1:1601 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3416
Practice Address - Country:US
Practice Address - Phone:516-622-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383031363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics