Provider Demographics
NPI:1871876912
Name:BRUNNER, SAMANTHA (PA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LENHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:300 MERIDIAN CENTRE BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MERIDIAN CENTRE BLVD STE 320
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3984
Practice Address - Country:US
Practice Address - Phone:585-463-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23015126363AM0700X
NY015126363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03775239Medicaid