Provider Demographics
NPI:1962040105
Name:FANOK, SAMANTHA NOELLE (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NOELLE
Last Name:FANOK
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 BENNETTS MILLS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4514
Mailing Address - Country:US
Mailing Address - Phone:732-547-0972
Mailing Address - Fax:
Practice Address - Street 1:123 BENNETTS MILLS RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-4514
Practice Address - Country:US
Practice Address - Phone:732-547-0972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT00228400235500000X
NJ25MP00788600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist