Provider Demographics
NPI:1730625799
Name:BUCK, SAMARA GWEN (PA-C)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:GWEN
Last Name:BUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMARA
Other - Middle Name:GWEN
Other - Last Name:SPOTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3159 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-3907
Mailing Address - Country:US
Mailing Address - Phone:231-233-7981
Mailing Address - Fax:
Practice Address - Street 1:1670 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1863
Practice Address - Country:US
Practice Address - Phone:231-672-2400
Practice Address - Fax:231-672-2401
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant