Provider Demographics
NPI:1003702630
Name:TAVAREZ, SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TAVAREZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1722
Mailing Address - Fax:315-798-1872
Practice Address - Street 1:20 KELLOGG RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2825
Practice Address - Country:US
Practice Address - Phone:315-765-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant