Provider Demographics
NPI:1538617030
Name:GLASGOW, SAMANTHA MARIE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:GLASGOW
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 1:1033 ROUTE 31 STE 1
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502-8218
Mailing Address - Country:US
Mailing Address - Phone:315-986-2100
Mailing Address - Fax:315-538-0047
Practice Address - Street 1:1033 ROUTE 31
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502-8218
Practice Address - Country:US
Practice Address - Phone:315-986-2100
Practice Address - Fax:315-538-0047
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04559399Medicaid
NYJ400341592Medicare PIN