Provider Demographics
NPI:1942866926
Name:WARDAK, SAMANTHA ALICE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ALICE
Last Name:WARDAK
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 1:11610 SW 42ND ST UNIT 225
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-8077
Mailing Address - Country:US
Mailing Address - Phone:920-382-0299
Mailing Address - Fax:
Practice Address - Street 1:16040 PINES BLVD # P103
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1171
Practice Address - Country:US
Practice Address - Phone:954-301-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115962363A00000X
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant