Provider Demographics
NPI:1336988401
Name:SHORT, SAMANTHA MAY
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MAY
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WEAVERDALE LN
Mailing Address - Street 2:
Mailing Address - City:MINOA
Mailing Address - State:NY
Mailing Address - Zip Code:13116-1028
Mailing Address - Country:US
Mailing Address - Phone:315-264-7968
Mailing Address - Fax:
Practice Address - Street 1:5586 LEGIONNAIRE DR STE 1
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-3504
Practice Address - Country:US
Practice Address - Phone:315-699-2837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant