Basic Information
| Provider Information | |||||||||
| NPI: | 1629679360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAVADA | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2780 CLEVELAND AVE STE 819 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339015817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393433800 | ||||||||
| FaxNumber: | 2393433993 | ||||||||
| Practice Location | |||||||||
| Address1: | 2780 CLEVELAND AVE STE 819 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339015817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393433800 | ||||||||
| FaxNumber: | 2393433993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2020 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PAT9113572 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 108861100 | 05 | FL | MEDICAID |