Provider Demographics
NPI:1477622108
Name:MYERS, SAMANTHA LYNN (PAC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:MYERS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-8938
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-8938
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISM003586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP31355Medicare UPIN