Basic Information
| Provider Information | |||||||||
| NPI: | 1477622108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEONARD | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5701 BOW POINTE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2486258938 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 BOW POINTE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2486258938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | SM003586 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.