Samantha Marcoly

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA63751 Issued in CA

Practice address

4650 Lincoln Blvd
Marina del Rey, CA 90292-6306

Phone

(310) 448-5200

NPI assigned

Sep 29, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mission Viejo Emergency Medical Associates, Inc.

  • Emergency Medicine Physician
  • Laguna Beach, CA
  • NPI 1134355597
  Medicare reassignment
• Petrel Emergency Physicians, a Medical Corporation

  • Emergency Medicine Physician
  • Marina del Rey, CA
  • NPI 1154734663
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1664409600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1702512000000",
    "number": "1275257594",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4650 LINCOLN BLVD",
            "city": "MARINA DEL REY",
            "state": "CA",
            "postal_code": "902926306"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4650 LINCOLN BLVD",
            "city": "MARINA DEL REY",
            "state": "CA",
            "postal_code": "902926306",
            "telephone_number": "310-448-5200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MARCOLY",
        "first_name": "SAMANTHA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-09-29",
        "last_updated": "2023-12-14",
        "certification_date": "2023-12-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA63751",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Shikha Manoj Shah, DDS
• Sarah Janine Mansour, PHARM.D.
• Vladimir Manuel, M.D.
• Glenville Anthony March Jr., MD
• Marcia J Glenn MD & Associates Dermatology & Laser Med Ctr Inc
• Daniel R Marcus, M.D.
• Marina Acupuncture Center, Inc.
• Marina Cosmetic Implant Dentistry
• Marina Dental Center
• Marina Dental Center

• Physician Assistant in Marina del Rey, CA
• Providers in Marina del Rey, CA by specialty
• Physician Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.