Healthcare Provider Details

I. General information

NPI: 1508974213
Provider Name (Legal Business Name): PHILIP MERRILL SAMPSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 MAIN ST
LIVINGSTON CA
95334-1257
US

IV. Provider business mailing address

1140 MAIN ST
LIVINGSTON CA
95334-1257
US

V. Phone/Fax

Practice location:
  • Phone: 209-394-7913
  • Fax: 209-394-9093
Mailing address:
  • Phone: 209-394-7913
  • Fax: 209-394-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14693
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA14693
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: