Provider Demographics
NPI:1861978108
Name:PETROVSKI, SAMANTHA ROSE
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ROSE
Last Name:PETROVSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ROSE
Other - Last Name:KUZMANOVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24711 BROOKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4745
Mailing Address - Country:US
Mailing Address - Phone:586-722-8251
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294114163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse