Basic Information
| Provider Information | |||||||||
| NPI: | 1982149811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | CARA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLAUM | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | CARA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1101 STEWART AVENUE | ||||||||
| Address2: | SUITE 100 NORTH | ||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168388739 | ||||||||
| FaxNumber: | 5169924637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 STEWART AVENUE | ||||||||
| Address2: | SUITE 100 NORTH | ||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168388739 | ||||||||
| FaxNumber: | 5169924637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2017 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 020416 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | A400185700 | 01 | NY | MEDICARE | OTHER |