Provider Demographics
NPI:1902465883
Name:PROCHASKA, SAMANTHA L (AA)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:L
Last Name:PROCHASKA
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4665 DOUGLAS CIR NW STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3673
Mailing Address - Country:US
Mailing Address - Phone:330-499-5700
Mailing Address - Fax:330-498-4229
Practice Address - Street 1:4665 DOUGLAS CIR NW STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3673
Practice Address - Country:US
Practice Address - Phone:330-499-5700
Practice Address - Fax:330-498-4229
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000348367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant