Provider Demographics
NPI:1083175277
Name:PRAVDER, SAMANTHA HAYLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:HAYLE
Last Name:PRAVDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 45TH STREET
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407
Mailing Address - Country:US
Mailing Address - Phone:561-844-6363
Mailing Address - Fax:
Practice Address - Street 1:927 45TH STREET
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-844-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY3164382080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program