Provider Demographics
NPI:1982149811
Name:BRAVO, SAMANTHA CARA (PA)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:CARA
Last Name:BRAVO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:CARA
Other - Last Name:FLAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1101 STEWART AVENUE
Mailing Address - Street 2:SUITE 100 NORTH
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-838-8739
Mailing Address - Fax:516-992-4637
Practice Address - Street 1:1101 STEWART AVENUE
Practice Address - Street 2:SUITE 100 NORTH
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-838-8739
Practice Address - Fax:516-992-4637
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400185700OtherMEDICARE