Provider Demographics
NPI:1952649162
Name:KORTH, SAMANTHA J (PA)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:J
Last Name:KORTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:J
Other - Last Name:KUBE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3206 N 121ST PLZ
Mailing Address - Street 2:APT 363
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-4110
Mailing Address - Country:US
Mailing Address - Phone:605-660-3073
Mailing Address - Fax:
Practice Address - Street 1:16909 LAKESIDE HILLS CT
Practice Address - Street 2:#208
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-4664
Practice Address - Country:US
Practice Address - Phone:402-758-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1055363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical