Basic Information
| Provider Information | |||||||||
| NPI: | 1104079995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RASTAGH | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 222443 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330222443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549294036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7481 W OAKLAND PARK BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAUDERHILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333194985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547717743 | ||||||||
| FaxNumber: | 9547717748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9186588 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | ARNP9186588 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.