Healthcare Provider Details

I. General information

NPI: 1275263428
Provider Name (Legal Business Name): SAMUEL ROBERT STONE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 E FLAMINGO AVE
NAMPA ID
83687-3138
US

IV. Provider business mailing address

921 S 8TH AVE STOP 8253
POCATELLO ID
83209-0002
US

V. Phone/Fax

Practice location:
  • Phone: 208-205-1100
  • Fax:
Mailing address:
  • Phone: 208-282-4726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2335
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: