Provider Demographics
NPI:1831187459
Name:HARGROVE, SAM P (PA)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:P
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 ORIENTA AVE
Mailing Address - Street 2:SUITE 1191
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5619
Mailing Address - Country:US
Mailing Address - Phone:407-329-7675
Mailing Address - Fax:
Practice Address - Street 1:745 ORIENTA AVE
Practice Address - Street 2:STE.1191
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5619
Practice Address - Country:US
Practice Address - Phone:888-551-3184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0001956363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0246Medicare ID - Type Unspecified
S51009Medicare UPIN