Provider Demographics
NPI:1427340934
Name:HANES, SAMANTHA RAZAVI (ARNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAZAVI
Last Name:HANES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 700
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4230
Mailing Address - Country:US
Mailing Address - Phone:904-399-5678
Mailing Address - Fax:904-399-8488
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 700
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-399-5678
Practice Address - Fax:904-399-8488
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-12326-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015482700Medicaid
FLIF867ZMedicare PIN