1114252863 NPI number — MS. SAMANTHA KANTOR LAISURE-POOL PA-C

Table of content: MS. SAMANTHA KANTOR LAISURE-POOL PA-C (NPI 1114252863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114252863 NPI number — MS. SAMANTHA KANTOR LAISURE-POOL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAISURE-POOL
Provider First Name:
SAMANTHA
Provider Middle Name:
KANTOR
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KANTOR
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
ERIN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114252863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6320 W UNION HILLS DR STE A100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-233-1300
Provider Business Mailing Address Fax Number:
623-233-1313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6320 W UNION HILLS DR STE A100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-1099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-233-1300
Provider Business Practice Location Address Fax Number:
623-233-1313
Provider Enumeration Date:
10/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  4445 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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