Provider Demographics
NPI:1285343038
Name:MAZUR, SAMANTHA FAY (DNP, RN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:FAY
Last Name:MAZUR
Suffix:
Gender:F
Credentials:DNP, RN, CPNP-PC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:FAY
Other - Last Name:DEYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2090
Mailing Address - Fax:414-266-3157
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2090
Practice Address - Fax:414-266-3157
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI220932163WP0200X
WI13078363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics