Provider Demographics
NPI:1821490459
Name:GRUNDEMANN, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRUNDEMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:GRACE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:212 WINSTON DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-8526
Mailing Address - Country:US
Mailing Address - Phone:269-781-9867
Mailing Address - Fax:
Practice Address - Street 1:212 WINSTON DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8526
Practice Address - Country:US
Practice Address - Phone:269-781-6897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant