Provider Demographics
NPI:1104603695
Name:AUFDERHAAR, SAMANTHA MAE (DNP, CRNA)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MAE
Last Name:AUFDERHAAR
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WOODLAND KNOLLS RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61548-9432
Mailing Address - Country:US
Mailing Address - Phone:608-886-8719
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI145026367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered