Provider Demographics
NPI:1689438087
Name:PAVOLKO, SAMANTHA LYNN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:PAVOLKO
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 1:167 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-2042
Mailing Address - Country:US
Mailing Address - Phone:484-515-8487
Mailing Address - Fax:
Practice Address - Street 1:3356 BIRNEY PLZ
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1560
Practice Address - Country:US
Practice Address - Phone:570-347-7790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT032106261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy