Provider Demographics
NPI:1245985209
Name:BOSSAK, SAMANTHA RUTH
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RUTH
Last Name:BOSSAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13686
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-0686
Mailing Address - Country:US
Mailing Address - Phone:912-600-1137
Mailing Address - Fax:912-806-4995
Practice Address - Street 1:4B SKIDAWAY VILLAGE WALK
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31411-3141
Practice Address - Country:US
Practice Address - Phone:912-598-6322
Practice Address - Fax:912-809-4995
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily