Provider Demographics
NPI:1154108256
Name:HEUER, SAMANTHA TANNY (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TANNY
Last Name:HEUER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 BAXTER AVE APT 401
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2270
Mailing Address - Country:US
Mailing Address - Phone:606-465-8715
Mailing Address - Fax:
Practice Address - Street 1:2800 BRECKENRIDGE LN STE 400
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1402
Practice Address - Country:US
Practice Address - Phone:502-895-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant