Provider Demographics
NPI:1942039318
Name:FARLEY, SAMUEL COLT
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:COLT
Last Name:FARLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR RD STE 580
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1321
Mailing Address - Country:US
Mailing Address - Phone:414-476-0430
Mailing Address - Fax:
Practice Address - Street 1:2600 N MAYFAIR RD STE 580
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1321
Practice Address - Country:US
Practice Address - Phone:414-732-2715
Practice Address - Fax:414-476-3242
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8181-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8181-23OtherSTATE LICENSE