Provider Demographics
NPI:1003677121
Name:CUNDIFF, SAMUEL ADAM (PA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ADAM
Last Name:CUNDIFF
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 1:2781 RUBY RIVER DR APT 1103
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-6524
Mailing Address - Country:US
Mailing Address - Phone:859-475-6773
Mailing Address - Fax:
Practice Address - Street 1:1350 BULL LEA RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1247
Practice Address - Country:US
Practice Address - Phone:859-246-8000
Practice Address - Fax:859-246-8032
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA3445363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical