Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 310476 | NY |
NPI | 1114417607 |
---|---|
Provider Name | Samantha Bax |
First Address | Potsdam, NY 13676-1799 |
Second Address | Potsdam, NY 13676-1799 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2018 |
Last Update Date | 02/02/2022 |