Provider Demographics
NPI:1922593367
Name:SAMAK, JAY K (PA-C)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:K
Last Name:SAMAK
Suffix:
Gender:M
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 1:4435 US HIGHWAY 98 N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-0402
Mailing Address - Country:US
Mailing Address - Phone:863-858-8000
Mailing Address - Fax:
Practice Address - Street 1:4435 US HIGHWAY 98 N
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809
Practice Address - Country:US
Practice Address - Phone:863-858-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08068363A00000X
FLPA9111308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant